(Editorial) Assisted dying: a question of when, not if

Richard Hurley, Tessa Richards, Fiona Godlee

British Medical Journal

Abstract

Doctors’ views on assisted dying are split, and most doctors’ organisations take no position on the issue; a few—including the BMA—oppose legalisation. Their stance matters: lawmakers and judges regularly seek, and listen to, their views. The BMJ has called for the professions’ representatives to take a position of neutrality—neither in support nor opposition—on the grounds that doctors should not obstruct a decision that is for society and parliament to make.

Engaged neutrality is far from an abdication of responsibility. It honours the diversity in professionals’ opinion. We believe that it also enables organisations to facilitate and fully engage with much needed societal conversations about death and what it means to die well.

Neutral organisations can be closely involved in drafting laws and guidelines, which would be impossible if they opposed their existence. They can lobby for the interests of doctors who do not wish to participate, as well as of doctors who do. . .


Hurley R, Richards T, Godlee F. (Editorial) Assisted dying: a question of when, not if. Br. Med. J. 2021;374(2128)

Organ donation after euthanasia starting at home in a patient with multiple system atrophy

Najat Tajaâte, Nathalie van Dijk, Elien Pragt, David Shaw,A. Kempener‑Deguelle, Wim de Jongh, Jan Bollen,Walther van Mook

BMC Medical Ethics

Abstract

Background: A patient who fulfils the due diligence requirements for euthanasia, and is medically suitable, is able to donate his organs after euthanasia in Belgium, the Netherlands and Canada. Since 2012, more than 70 patients have undergone this combined procedure in the Netherlands. Even though all patients who undergo euthanasia are suf‑ fering hopelessly and unbearably, some of these patients are nevertheless willing to help others in need of an organ.

Organ donation after euthanasia is a so‑called donation after circulatory death (DCD), Maastricht category III procedure, which takes place following cardiac arrest, comparable to donation after withdrawal of life sustaining therapy in critically ill patients. To minimize the period of organ ischemia, the patient is transported to the operating room immediately after the legally mandated no‑touch period of 5 min following circulatory arrest. This means that the organ donation procedure following euthanasia must take place in the hospital, which appears to be insurmountable to many patients who are willing to donate, since they already spent a lot of time in the hospital.

Case presentation: This article describes the procedure of organ donation after euthanasia starting at home (ODAEH) following anesthesia in a former health care professional suffering from multiple system atrophy. This case is unique for at least two reasons. He spent his last conscious hours surrounded by his family at home, after which he underwent general anaesthesia and was intubated, before being transported to the hospital for euthanasia and organ donation. In addition, the patient explicitly requested the euthanasia to be performed in the preparation room, next to the operating room, in order to limit the period of organ ischemia due to transport time from the intensive care unit to the operating room. The medical, legal and ethical considerations related to this illustrative case are subsequently discussed.

Conclusions: Organ donation after euthanasia is a pure act of altruism. This combined procedure can also be performed after the patient has been anesthetized at home and during transportation to the hospital.


Tajaâte N, van Dijk N, Pragt E, Shaw D, Kempener‑Deguelle A, de Jongh W et al. Organ donation after euthanasia starting at home in a patient with multiple system atrophy. BMC Medical Ethics. 2021;22(120).

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

Abstract

Background The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.

Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.

Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.

Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.

Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.


Groenewoud AS, Atsma F, Arvin M, Westert GP, Boer TA. Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation BMJ Support Palliat Care. 2021 Jan 14:bmjspcare-2020-002573. doi: 10.1136/bmjspcare-2020-002573. Epub ahead of print. PMID: 33446488.

The Declaration of Geneva: Conscience, Dignity and Good Medical Practice

Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva

World Medical Journal

Since 1948 the Declaration of Geneva (the Declaration) has insisted that physicians must practise medicine “with conscience and dignity.” In 2017 this provision was modified by adding, “and in accordance with good medical practice” [1].

Good medical practice in Canada is said to include providing euthanasia and assisted suicide or arranging for someone else to do so. From this perspective, physicians who cannot in conscience kill their patients or collaborate in killing are not acting “in accordance with good medical practice,” and – some might say – the revised Declaration.

However, this merely literal application of the text cannot be correct, since the WMA later reaffirmed its support for physicians who refuse to provide or refer for euthanasia and assisted suicide even where they are considered good medical practice [2]. A reading informed by the history of the document is necessary and consistent with the care taken in its revision [1]. This yields a rational and coherent account of the relationship of conscience and dignity to medical practice.


Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR, Leiva R. The Declaration of Geneva: Conscience, Dignity and Good Medical Practice . WMJ [Internet]. 2020 Aug; 66(4): 43-47.

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues

Leonie Herx, Margaret Cottle, John Scott

World Medical Journal

Abstract

This paper will balance recent portrayals in the popular and medical media that imply only a positive impact as a result of the introduction of euthanasia into Canada’s health system [3–4]. Evidence will be presented to demonstrate that there are significant negative and dangerous consequences of this radical shift for medicine, and particularly for palliative medicine. These include the widening and loosening of already ambiguous eligibility criteria, the lack of adequate and appropriate safeguards, the erosion of conscience protection for health care professionals, and the failure of adequate over- sight, review and prosecution for non-compliance with the legislation. Indeed, what we have seen over the past four years is that “the slope has in fact proved every bit as slippery as the critics had warned” . . . Euthanasia is not the panacea that proponents promise. Its legalization and subsequent rapid normalization have had serious negative effects on Canadian medicine and on Canadian society as a whole. We urge the WMA and our colleagues around the world to look beyond the simplistic media reports and to monitor developments in Canada carefully and wisely before making any changes in their own country’s legal frame- work for medical practice.


Herx L, Cottle M, Scott J. The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues. World Medical Journal020. 2020;66(2):28-37.

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Mary Kathleen Deutscher Heilman, Tracy J. Trothen

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Abstract: Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one’s conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.


Heilman MKD, Trothen TJ. Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada. J Med Ethics. 2020;46(2):123-127. doi:10.1136/medethics-2019-105855

The Independence of Judicial Conscience

Barry W. Bussey

The Independence of Judicial Conscience

. . . Competence and character are no longer the sole criteria for evaluating a judicial nominee; candidates face a climate which demands they have the “correct” moral opinions on fundamental human rights issues. Those
issues include abortion, marriage, and the euphemistically-termed Medical Assistance in Dying (MAiD). . . to disregard the judicial conscience is to compromise the dignity of the judge, the worth of her convictions, the fullness of her humanity. Even more, it undermines the very essence of what distinguishes a democratic society characterized by diversity, inclusion, and freedom.


Bussey BW. The Independence of Judicial Conscience. J Christian Legal Thought. 2019; 9(2): 34-37.

Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Julie Allard, Marie-Chantal Fortin

Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Résumé

Depuis décembre 2015, l’aide médicale à mourir, une pratique au centre de nombreux débats éthiques, est légalisée dans la province du Québec, au Canada. Ce nouveau type de décès a créé un tout nouveau contexte pour le don d’organes, soit le don d’organes après l’aide médicale à mourir. Le prélèvement des organes s’effectue alors suivant le protocole habituel du don d’organes après décès cardiocirculatoire contrôlé (catégorie Maastricht III), un protocole qui suscitait déjà de nombreux questionnements médico-éthiques. En outre, l’amalgame des deux pratiques soulève de nouveaux enjeux éthiques qui peuvent se traduire par des objections de conscience chez les médecins directement impliqués dans l’aide médicale à mourir et/ou le don d’organes. Or, une telle objection de conscience peut-elle être acceptable ? Nous tenterons de répondre à cette question en trois temps : d’abord, par un bref historique de l’objection de conscience ; ensuite, par une revue des débats actuels sur ce sujet ; enfin, par l’examen, à l’aide de critères recensés dans la littérature, de cas où les médecins refuseraient de participer au don d’organes après l’aide médicale à mourir.

Summary

Medical assistance in dying, a much debated practice in ethical literature, is practiced since 2015 in the province of Québec, Canada. Its practice has opened the door to organ donation after medical assistance in dying. This type of donation is possible through donation after controlled cardiocirculatory death (Maastricht III category), a procedure that also raises many ethical questions. Combining these two practices raises new ethical issues and could therefore generate conscientious objections from physicians directly involved in medical assistance in dying and/or organ donation. Would conscientious objection be acceptable in this context? To answer this question, we present a brief history of conscientious objection, an overview of the actual debates on conscientious objection and we will examine the case of the physician who would object to participate in organ donation after medical assistance in dying using existing criteria.


Allard J, Forin M.-C. Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec. Éthique & Santé; 2019 Sep; 16(3): 125-132

Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium

Nicholas Gilbo, Ina Jochmans, Daniel Jacobs-Tulleneers-Thevissen, Albert Wolthuis, Mauricio Sainz-Barriga, Jacques Pirenne, Diethard Monbaliu

Journal of the American Medical Association

Abstract

Transplantation of organs donated after euthanasia may help alleviate the critical organ shortage.1 However, aside from preliminary data on lung transplantation,2 data on graft and patient survival following transplantation of organs donated after euthanasia are unavailable. Because donation after euthanasia entails a period of detrimental warm ischemia that hampers graft survival, similar to donation after circulatory death,3 results after transplantation of this type of graft need to be carefully evaluated.


Gilbo N, Jochmans I, Jacobs-Tulleneers-Thevissen D, Wolthuis A, Sainz-Barriga M, Pirenne  J, Monbaliu D.  Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium. JAMA. 2019;322(1):78-80. doi:10.1001/jama.2019.6553

Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy

James Downar, Sam D. Shemie, Clay Gillrie, Marie-Chantal Fortin, Amber Appleby, Daniel Z. Buchman, Christen Shoesmith, Aviva Goldberg, Vanessa Gruben, Jehan Lalani, Dirk Ysebaert, Lindsay Wilson and Michael D. Sharpe

Canadian Medical Association Journal

KEY POINTS

  • First-person consent for organ donation after medical assistance in dying (MAiD) or withdrawal of life-sustaining measures (WLSM) should be an option in jurisdictions that allow MAiD or WLSM and donation after circulatory determination of death.
  • The most important ethical concern — that the decision for MAiD or WLSM is being driven by a desire to donate organs — should be managed by ensuring that any discussion about organ donation takes place only after the decision for MAiD or WLSM is made.
  • If indications for MAiD change, this guidance for policies and the practice of organ donation after MAiD should be reviewed to ensure that the changes have not created new ethical or practical concerns. . .
  • [Full text]

Downar J, Shemie SD, Gillrie C, Fortin M-C, Amber Appleby A, Buchman DZ, Shoesmith C, Goldberg A, Gruben V, Lalani J, Ysebaert D, Wilson L, Sharpe MD.  Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy. CMAJ. 2019 Jun 3;191(22):E604-E613. doi: 10.1503/cmaj.181648.