Protection of Conscience Project Library
Service, not Servitude
Extract
Once we have concluded that death is what is in the best interest of an infant, it is unreasonable not to bring about this death as painlessly and as much controlled in terms of timing by the parents as is feasible.
Schuklenk U. Physicians can justifiably euthanize certain severely impaired neonates. J Thorac Cardiovasc Surg. 2015 Feb;149(2):535-537.
Abstract
Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.
Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.
Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.
Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.
Bolt EE, Snijdewind MC, Willems DL, van der Heide A, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics doi:10.1136/medethics-2014-102150
Extract
For most Canadians, the arguments that began on Oct. 14, 2014, at the Supreme Court in Ottawa are about medical aid in dying. But what is really at stake in Carter et al v Attorney General of Canada et al is Canadian law itself, the meaning of its guarantees, promises and injunctions.
Koch T. The law and physician-assisted dying. Can Med Assoc J. 2014 Nov 18;186(17):1336.
Abstract
Objective To examine medical students’ views on conscientious objection and controversial medical procedures.
Methods: Questionnaire study among Norwegian 5th and 6th year medical students.
Results: Five hundred and thirty-one of 893 students (59%) responded. Respondents object to a range of procedures not limited to abortion (up to 19%)—notably euthanasia (62%), ritual circumcision for boys (52%), assisted reproduction for same-sex couples (9.7%) and ultrasound in the setting of prenatal diagnosis (5.0%). A small minority (4.9%) would object to referrals for abortion. In the case of abortion, up to 55% would tolerate conscientious refusals, whereas 42% would not. Higher proportions would tolerate refusals for euthanasia (89%) or ritual circumcision for boys (72%).
Discussion: A majority of Norwegian medical students would object to participation in euthanasia or ritual circumcision for boys. However, in most settings, many medical students think doctors should not be able to refuse participation on grounds of conscience. A minority would accept conscientious refusals for procedures they themselves do not object to personally. Most students would not accept conscientious refusals for referrals.
Conclusions: Conscientious objection remains a live issue in the context of several medical procedures not limited to abortion. Although most would want a right to object to participation in euthanasia, tolerance towards conscientious objectors in general was moderate or low.
Nordstrand SJ, Nordstrand MA, Nortvedt P, Magelssen M. Medical students’ attitudes towards conscientious objection: a survey. J Med Ethics 2014;40:609-612 doi:10.1136/medethics-2013-101482
Abstract
This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.
Bernheim JL, Distelmans W, Mullie A, Ashby MA. Questions and Answers on the Belgian Model of Integral End-of-Life Care: Experiment? Prototype?: “Eu-Euthanasia”: The Close Historical, and Evidently Synergistic, Relationship Between Palliative Care and Euthanasia in Belgium: An Interview With a Doctor Involved in the Early Development of Both and Two of His Successors. J Bioethic Inq. 2014;11(4):507-529.
Three physicians and a lawyer have written an article published in the May issue of the Canadian Medical Association Journal.[1] The lead author, Dr. James Downar, is co-chair of a euthanasia/assisted suicide advocacy group.
Anticipating a change in the law, the authors warn that “well-rehearsed debates” about sanctity of life and personal autonomy “may become obsolete.”
“We need to start to answer some challenging questions in preparation for the possibility that physician-assisted death will be available in Canada soon,” they write.
Among the questions they pose, one raises two particularly sensitive issues:
Will physicians who are conscientious objectors be obliged to present physician-assisted death as an option to patients and facilitate transfers of patients to other physicians or facilities?
As a matter of law and ethics, physicians are expected to advise patients of all reasonable legal options for treatment so that patients can provide informed consent to it. However, many physicians who are strongly opposed to euthanasia and assisted suicide may view the “presentation of an option” for either procedure as inherently abusive of vulnerable patients. This problem does not usually arise with respect to other morally contested procedures, like abortion or contraception.
A requirement to “facilitate transfers” of patients would probably be acceptable if it involved only the kind of cooperation normally involved in the transfer of records when a patient is taken on by a different physician; this is all that is required in Belgium, Oregon and Washington State. However, a demand that objecting physicians refer patients or actively initiate transfers would be resisted by those who would consider such actions to involve unacceptable complicity in killing. The Supreme Court of the Philippines recognized this issue when it struck down a mandatory referral requirement in the country’s Reproductive Health Law as an unconstitutional violation of freedom of conscience.
Murphy S. Canadian physicians warned to get ready for euthanasia and assisted suicide [Internet]. Powell River, BC: Protection of Conscience Project; 2014 May 13 [Updated 2021 Mar 09].
Notes
1. Downar J, Bailey TM, Kagan J, Librach SL. Physician-assisted death: time to move beyond Yes or No. CMAJ 2014 May 13;186(8):567-8. doi: 10.1503/cmaj.140204. Epub 2014 Apr 7.
Abstract
Our goal in this article is to explicate the way, and the extent to which, euthanasia can be voluntary from both the perspective of the patient and the perspective of the health care providers involved in the patient’s care. More significantly, we aim to challenge the way in which those engaged in ongoing philosophical debates regarding the morality of euthanasia draw distinctions between voluntary, involuntary, and nonvoluntary euthanasia on the grounds that drawing the distinctions in the traditional manner (1) fails to reflect what is important from the patient’s perspective and (2) fails to reflect the significance of health care providers’ interests, including their autonomy and integrity.
Stoyles BJ, Costreie S. Rethinking Voluntary Euthanasia. J Med Philos (2013) 38 (6): 674-695. doi: 10.1093/jmp/jht045
Abstract
The legalization of physician-assisted death in states such as Washington and Oregon has presented defining ethical issues for hospice programs because up to 90% of terminally ill patients who use the state-regulated procedure to end their lives are enrolled in hospice care. The authors recently partnered with the Washington State Hospice and Palliative Care Organization to examine the policies developed by individual hospice programs on program and staff participation in the Washington Death with Dignity Act. This article sets a national and local context for the discussion of hospice involvement in physician-assisted death, summarizes the content of hospice policies in Washington State, and presents an analysis of these findings. The study reveals meaningful differences among hospice programs about the integrity and identity of hospice and hospice care, leading to different policies, values, understandings of the medical procedure, and caregiving practices. In particular, the authors found differences 1) in the language used by hospices to refer to the Washington statute that reflect differences among national organizations, 2) the values that hospice programs draw on to support their policies, 3) dilemmas created by requests by patients for hospice staff to be present at a patient’s death, and 4) five primary levels of noninvolvement and participation by hospice programs in requests from patients for physician-assisted death. This analysis concludes with a framework of questions for developing a comprehensive hospice policy on involvement in physician-assisted death and to assist national, state, local, and personal reflection.
Campbell CS, Black MA. Dignity, death, and dilemmas: A study of Washington hospices and physician-assisted death. J Pain Symptom Manage. 2013 Jul 3. pii: S0885-3924(13)00270-4. doi: 10.1016/j.jpainsymman.2013.02.024. [Epub ahead of print]
Abstract
Introduction or background
The public assumes that if euthanasia and assisted suicide were to be legalized they would be carried out by physicians.
Sources of data
In furthering critical analysis, we supplement the discourse in the ethics and palliative care literature with that from medical education and evolving jurisprudence.
Areas of agreement
Both proponents and opponents agree that the values of respect for human life and for individuals’ autonomy are relevant to the debate.
Areas of controversy
Advocates of euthanasia and assisted suicide give priority to the right to personal autonomy and avoid discussions of harmful impacts of these practices on medicine, law and society. Opponents give priority to respect for life and identify such harmful effects. These both require euthanasia to remain legally prohibited.
Growing points
Proposals are emerging that if society legalizes euthanasia it should not be mandated to physicians.
Areas timely for developing research
The impact of characterizing euthanasia as ‘medical treatment’ on physicians’ professional identity and on the institutions of medicine and law should be examined in jurisdictions where assisted suicide and euthanasia have been de-criminalized.
Boudreau JD, Somerville MA. Euthanasia is not medical treatment. Br Med Bull. 2013;106(1):45-66.
Journal Summary
In Flanders (the Dutch-speaking, northern part of Belgium), in the course of the last ten years, physician-assisted dying and euthanasia have become embedded in palliative care. Paul Vanden Berghe, Arsène Mullie, Marc Desmet and Gert Huysmans, from the Federation of Palliative Care Flanders, describe how this major change happened and what issues it raises.
Berghe PV, Mullie A, Desmet M, Huysmans G. Assisted dying – the current situation in Flanders: euthanasia embedded in palliative care. European J Palliative Care. 2013;20(6):266-272.