Richard Hurley, Tessa Richards, Fiona Godlee
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)
Najat Tajaâte, Nathalie van Dijk, Elien Pragt, David Shaw,A. Kempener‑Deguelle, Wim de Jongh, Jan Bollen,Walther van Mook
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).
Christopher J Einolf
Because of the difficulties in researching torturers, little is known about how they are recruited, trained, and authorized, and how they morally justify their actions. This study examines oral history testimonies from 14 former torturers in Saddam Hussein’s Iraq. Torturers volunteered for jobs in the security services, and attributed their choice of career to psychologically traumatic childhoods. Torturers were trained to think of their victims as subhuman and dangerous, and to cultivate mercilessness as a type of strength. They carried out torture under direct orders, and two were tortured themselves when they failed to obey. They justified their actions morally by diffusing responsibility, blaming victims, and using just-cause thinking. Overall, the findings show that there is no single path to becoming a torturer, as there is great variation even among torturers from a single country. Much more research is needed to fully understand how torturers think and work.
Einolf CJ. How torturers are made: Evidence from Saddam Hussein’s Iraq. Journal of Human Rights. 2021;20(4):381-395.
Philip A. Pizzo,David Spiegel, Michelle M. Mello
In December 2020, less than a year after severe acute respiratory syndrome coronavirus 2 was identified as the cause of the coronavirus pandemic, an extraordinary collaboration between scientists, the pharmaceutical industry, and government led to 2 highly efficacious, safe vaccines being approved by the US Food and Drug Administration to prevent coronavirus disease 2019 (COVID-19) infection.1,2 Had the US been in its expected role as a global leader in medicine and public health, this would have been a fitting capstone of US commitment to science and how that can change the course of morbidity and mortality related to a frightening new disease.
However, a less flattering story emerged about the inadequate US response to COVID-19. A number of leaders in federal, state, and local government, guided by political exigency and recommendations from a small number of physicians and scientists who ignored or dismissed science, refused to promote sensible, effective policies such as mask wearing and social distancing. This contributed to the US having more infections and deaths than other developed nations in proportion to population size . . .
Among the ways in which science-based public health evidence has been dismissed in the US is the replacement of highly experienced experts advising national leaders with persons who appear to have been chosen because of their willingness to support government officials’ desire to discount the significance of the pandemic. . .
. . . History is a potent reminder of tragic circumstances when physicians damaged the public health, from promoting eugenics to participating in the human experiments that took place in Tuskegee to asserting erroneously that vaccines cause autism. It can be difficult to hold physicians accountable, especially when they are acting in policy roles in which malpractice lawsuits will not succeed. Professional self-regulation serves as the primary vehicle for accountability and is critical if trust in science and medicine is to be maintained.
To that end, action from within the medical profession is an important but underused strategy. . .
Pizzo PA, Spiegel D, Mello MM. When Physicians Engage in Practices That Threaten the Nation’s Health. JAMA; 2021 Feb 04. Published online February 04, 2021. doi:10.1001/jama.2021.0122
Human germline genome editing is increasingly being seen as acceptable provided certain conditions are satisfied. Accordingly, genetic modifications would take place on eggs or sperm (or their precursor cells) as well as very early embryos for the purpose of bringing children into existence with or without particular genetic traits. In this context, a number of already discussed and separate arguments, such as the (1) synecdoche, (2) non-identity (3) inherent equality and (4) expressivist arguments, can be brought together in the new context of examining, from an ethical perspective, some of the possible consequences of such germline genome editing. In so doing, it becomes clear that these novel procedures are incompatible with the concept of equality in value and in worth of all human beings in a genuinely inclusive society. Such equality is expressed in Article 1 of the United Nations’ Universal Declaration of Human Rights which states that: ‘All human beings are born … equal in dignity and rights.’
MacKellar C. Why human germline genome editing is incompatible with equality in an inclusive society. New Bioeth. 2021 Mar;27(1):19-29. doi: 10.1080/20502877.2020.1869467. Epub 2021 Jan 17. PMID: 33459206.
A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer
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.
Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution.
Räsänen J. Twin pregnancy, fetal reduction and the ‘all or nothing problem’. J Med Ethics. 2020 Dec 21:medethics-2020-106938. doi: 10.1136/medethics-2020-106938. Epub ahead of print. PMID: 33443129.
Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva
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” .
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 . A reading informed by the history of the document is necessary and consistent with the care taken in its revision . 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.
Declaration of Geneva (1948), International Code of Medical Ethics (1949)
Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding
Practising Medicine “with conscience and dignity”
Beginning with the Declaration of Geneva (the Declaration), for over 70 years the World Medical Association (WMA) has maintained that physicians must practise medicine with conscience and dignity . On the Declaration’s 70th anniversary, seven associate WMA members raised serious concerns about their ability to remain in medical practice if they fulfil this obligation by refusing to support or collaborate in the killing of their patients by euthanasia and assisted suicide (EAS).The physicians practise in Canada, where euthanasia and assisted suicide (EAS) are legal, [3,4] recognized as therapeutic medical services by the national medical association [5,6] and provided through a public health care system controlled by the state, which also regulates medical practice and medical ethics. The national government is now poised to make EAS available for any serious and incurable medical condition, vastly increasing the number of patients legally eligible for the service .
In these circumstances, it is urgent to reassert that the duty to practise medicine “with conscience and dignity” includes unyielding refusal to do what one believes to be wrong even in the face of overwhelming pressure exerted by the state, the medico-legal establishment and even by medical leaders and colleagues. That the founders of the WMA not only supported but expected such principled obstinacy is evident in the WMA’s early history and the development of the Declaration, all of which remain surprisingly relevant . . .
Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR. The WMA and the Foundations of Medical Practice: Declaration of Geneva (1948), International Code of Medical Ethics (1949) . WMJ [Internet]. 2020 Aug; 66(3): 2-8.
Franck Mauvais-Jarvis, Noel Bairey Merz, Peter J Barnes, Roberta D Brinton, Juan-Jesus Carrero, Dawn L DeMeo, Geert J De Vries,C Neill Epperson, Ramaswamy Govindan, Sabra L Klein, Amedeo Lonardo, Pauline M Maki, Louise D McCullough, Vera Regitz-Zagrosek,Judith G Regensteiner, Joshua B Rubin, Kathryn Sandberg, Ayako Suzuki,
Clinicians can encounter sex and gender disparities in diagnostic and therapeutic responses. These disparities are noted in epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment. This Review discusses the fundamental influences of sex and gender as modifiers of the major causes of death and morbidity. We articulate how the genetic, epigenetic, and hormonal influences of biological sex influence physiology and disease, and how the social constructs of gender affect the behaviour of the community, clinicians, and patients in the health-care system and interact with pathobiology. We aim to guide clinicians and researchers to consider sex and gender in their approach to diagnosis, prevention, and treatment of diseases as a necessary and fundamental step towards precision medicine, which will benefit men’s and women’s health.
Mauvais-Jarvis F, Bairey Merz N, Barnes PJ, Brinton RD, Carrero J-J, DeMeo DL, De Vries GJ, Epperson CN, Govindan R, Klein SL, Lonardo A, Maki PM, McCullough LD, Regitz-Zagrosek V, Regensteiner JG, Rubin JB, Sandberg K, Suzuki A. Sex and gender: modifiers of health, disease, and medicine. The Lancet; 2020 Aug 22 396(10250): 565-582. DOI:https://doi.org/10.1016/S0140-6736(20)31561-0