Project Administrator, Author at Protection of Conscience Project Library

Euthanizing People Who Are ‘Tired of Life’ in Belgium

Raphael Cohen-Almagor, David Albert Jones, Chris Gastmans, Calum Mackellar

Euthanasia and Assisted Suicide: Lessons from Belgium

Abstract
In Belgium and in The Netherlands, a debate is developing about people who express a desire to end their lives although they do not suffer from an incurable, life-threatening disease. In 2000, a court in Haarlem in The Netherlands considered the case of 86-year-old Edward Brongersma who had expressed his wish to die to his general practitioner, Dr Philip Sutorius, claiming that death had ‘forgotten’ him, his friends and relatives were dead, and he experienced ‘a pointless and empty existence’. After repeated requests, Dr Sutorius euthanized his insisting patient and was then put on trial. The public prosecution recognized that Dr Sutorius fulfilled all the legal criteria but one: ‘hopeless and unbearable suffering.’ Therefore, the patient’s request should have been refused. The court did not discipline Dr Sutorius, saying that the patient was obsessed with his ‘physical decline’ and ‘hopeless existence’ and therefore was suffering ‘hopelessly and unbearably’. A spokesman for the Royal Dutch Medical Association reacted to the court judgment by saying that the definition of ‘unbearable suffering’ had been stretched too far and that ‘what is new is that it goes beyond physical or psychiatric illness to include social decline’. The then Justice Minister Benk Korthals said that being ‘tired of life’ is not sufficient reason for euthanasia. Since then, the debate as to whether physicians should comply with euthanasia requests of people who are ‘tired of life’ has been widened and many people in Belgium and in The Netherlands are calling for the law to be expanded in order to include similar patients. The methodology of this research is based on a critical review of the literature supplemented by communications with leading scholars and practitioners. First, concerns are raised about euthanizing people who say that they are ‘tired of life’. Some suggestions designed to improve the situation are offered. The Belgian legislators and medical establishment are invited to reflect and ponder so as to prevent potential abuse.

Cohen-Almagor R, Jones DA, Gastmans C, Mackellar C. Euthanizing People Who Are ‘Tired of Life’ in Belgium. In: Jones DA, Gastmans C, MacKellar C, editors. Euthanasia and Assisted Suicide: Lessons from Belgium. 2017;188-201. Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3052105

Assisted Dying Bill for England and Wales

Raphael Cohen-Almagor

Euthanasia and Assisted Suicide: Global Views on Choosing to End Life

Abstract
This paper is aimed to suggest an improved set of guidelines for physician-assisted suicide. Thus it is very practical, based on 25 years of research in eight countries and it does not expand on the underpinning theoretical basis for the guidelines. I have been an advocate of physician-assisted suicide and explained the reasoning elsewhere, primarily in The Right to Die with Dignity and Euthanasia in the Netherlands. I support the idea that patients should be able to decide the time of their death with the help and support of the medical profession. People have human dignity. At the end of their lives, the medical profession should respect their wishes and help them to the best of their abilities. By ‘dignity’ it is meant worthiness, merit. The Oxford English Dictionary defines it as “the state or quality of being worthy of honour or respect”. Kant explained that human beings are end in themselves and that for something to be an end in itself, “it doesn’t have mere relative value (a price) but has intrinsic value (i.e. dignity)”. He further elucidated that autonomy is the basis for the dignity of human nature and of every rational nature. Kant calls dignity an unconditional and incomparable worth that admits of no equivalent. All rational creatures have it, by virtue of their reason, and dignity constrains the ways in which we can legitimately interact. In a similar fashion, Dworkin asserted that individuals have a right to dignity because they are human. I argue that dignity is both objective and subjective concept. It is socially constructed and made up of values and feelings that one feels about oneself, about one’s self-worth and respect. It is further argued that legislation of physician-assisted suicide is a matter of moral necessity and political expediency.

Cohen-Almagor R. Assisted Dying Bill for England and Wales. In: Cholbia M editors. Euthanasia and Assisted Suicide: Global Views on Choosing to End Life. 2017;29-44.

The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine

Robert F Card

Cambridge Quarterly of Healthcare Ethics

Abstract
This article first critically reviews the major philosophical positions in the literature on conscientious objection and finds that they possess significant flaws. A substantial number of these problems stem from the fact that these views fail to assess the reasons offered by medical professionals in support of their objections. This observation is used to motivate the reasonability view , one part of which states: A practitioner who lodges a conscientious refusal must publicly state his or her objection as well as the reasoned basis for the objection and have these subjected to critical evaluation before a conscientious exemption can be granted (the reason-giving requirement). It is then argued that when defenders of the other philosophical views attempt to avoid granting an accommodation to spurious objections based on discrimination, empirically mistaken beliefs, or other unjustified biases, they are implicitly committed to the reason-giving requirement. This article concludes that based on these considerations, a reason-giving position such as the reasonability view possesses a decisive advantage in this debate.

Card RF. The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine. Camb Q Healthc Ethics 2017 Jan;26(1):82-96. doi: 10.1017/S0963180116000669

“She’s on her own”: a thematic analysis of clinicians’ comments on abortion referral

Nazeneen Homaifar, Lori Freedman,Valerie French

Abstract
Objective: The objective was to understand the motivations around and practices of abortion referral among women’s health providers.

Methods: We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician’s responses to open-ended questions on abortion referral thematically.

Results: Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion.

Conclusions: While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all.

Implications: Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure that women can access safe care.

Homaifar N, Freedman L,French V. “She’s on her own”: a thematic analysis of clinicians’ comments on abortion referral. Contraception. 2017 May;95(5):470-476. doi: 10.1016/j.contraception.2017.01.007. Epub 2017 Jan 25.

Tolerance, Professional Judgment, and the Discretionary Space of the Physician

Daneil P. Sulmasy

Abstract
Arguments against physicians’ claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke’s conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection.

Sulmasy DP. Tolerance, Professional Judgment, and the Discretionary Space of the Physician. Camb Q Healthc Ethics. 2017 Jan;26(1):18-31.

Conscientious non-objection in intensive care

Dominic Wilkinson

Abstract
Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

Wilkinson D. Conscientious non-objection in intensive care. Camb. Q. Healthc. Ethics. 2017;26(1):132-142.

How to Allow Conscientious Objection in Medicine While Protecting Patient Rights

Aaron Ancell, Walter Sinnott-Armstrong

Abstract
Paradigmatic cases of conscientious objection in medicine are those in which a physician refuses to provide a medical service or good because doing so would conflict with that physician’s personal moral or religious beliefs. Should such refusals be allowed in medicine? We argue that (1) many conscientious objections to providing certain services must be allowed because they fall within the range of freedom that physicians have to determine which services to offer in their practices; (2) at least some conscientious objections to serving particular groups of patients should be allowed because they are not invidiously discriminatory; and (3) even in cases of invidiously discriminatory conscientious objections, legally prohibiting individual physicians from refusing to serve patients on the basis of such objections is not always the best solution.

Ancell A, Sinnott-Armstrong W. How to Allow Conscientious Objection in Medicine While Protecting Patient Rights. Camb Q Healthc Ethics. 2017 Jan;26(1):120-131.

The cost of conscience: Kant on Conscience and Conscientious Objection

Jeanette Kennett

Abstract
The spread of demands by physicians and allied health professionals for accommodation of their private ethical, usually religiously based, objections to providing care of a particular type, or to a particular class of persons, suggests the need for a re-evaluation of conscientious objection in healthcare and how it should be regulated. I argue on Kantian grounds that respect for conscience and protection of freedom of conscience is consistent with fairly stringent limitations and regulations governing refusal of service in healthcare settings. Respect for conscience does not entail that refusal of service should be cost free to the objector. I suggest that conscientious objection in medicine should be conceptualized and treated analogously to civil disobedience.

Kennett J. The cost of conscience: Kant on Conscience and Conscientious Objection. Cam Quart Healthcare Ethics 2017 Jan;26(1):69-81.

The Legal Ethical Backbone of Conscientious Refusal

Christian Munthe, Morten Ebbe Juul Nielsen

Abstract
This article analyzes the idea of a legal right to conscientious refusal for healthcare professionals from a basic legal ethical standpoint, using refusal to perform tasks related to legal abortion (in cases of voluntary employment) as a case in point. The idea of a legal right to conscientious refusal is distinguished from ideas regarding moral rights or reasons related to conscientious refusal, and none of the latter are found to support the notion of a legal right. Reasons for allowing some sort of room for conscientious refusal for healthcare professionals based on the importance of cultural identity and the fostering of a critical atmosphere might provide some support, if no countervailing factors apply. One such factor is that a legal right to healthcare professionals’ conscientious refusal must comply with basic legal ethical tenets regarding the rule of law and equal treatment, and this requirement is found to create serious problems for those wishing to defend the idea under consideration. We conclude that the notion of a legal right to conscientious refusal for any profession is either fundamentally incompatible with elementary legal ethical requirements, or implausible because it undermines the functioning of a related professional sector (healthcare) or even of society as a whole.

Munthe C, Nielsen MEJ. The Legal Ethical Backbone of Conscientious Refusal. Cambridge Quarterly of Healthcare Ethics. Cambridge Quarterly of Healthcare Ethics. 2017 Jan; 26(1): 59-68. doi:10.1017/S0963180116000645

The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine

Robert F. Card

Abstract
This article first critically reviews the major philosophical positions in the literature on conscientious objection and finds that they possess significant flaws. A substantial number of these problems stem from the fact that these views fail to assess the reasons offered by medical professionals in support of their objections. This observation is used to motivate the reasonability view, one part of which states: A practitioner who lodges a conscientious refusal must publicly state his or her objection as well as the reasoned basis for the objection and have these subjected to critical evaluation before a conscientious exemption can be granted (the reason-giving requirement). It is then argued that when defenders of the other philosophical views attempt to avoid granting an accommodation to spurious objections based on discrimination, empirically mistaken beliefs, or other unjustified biases, they are implicitly committed to the reason-giving requirement. This article concludes that based on these considerations, a reason-giving position such as the reasonability view possesses a decisive advantage in this debate.

Card RF. The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine. Cambridge Quarterly of Healthcare Ethics. 2017 Jan; 26(1): 82-96. DOI: https://doi.org/10.1017/S0963180116000669.