Journal Articles Archives - Page 9 of 67 - Protection of Conscience Project Library

Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada

Emmanuelle Bélanger, Anna Towers, David Kenneth Wright, Yuexi Chen, Golda Tradounsky, Mary Ellen Macdonald

Abstract
Objectives: In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?

Methods: We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.

Results: Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients’ autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.

Conclusions: This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

Bélanger E, Towers A, Wright DK, Chen Y, Tradounsky G, Macdonald ME. Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada. J Med Ethics 2019;45:48-53.

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

Thomas David Riisfeldt

Abstract
Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.

Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. J Med Ethics 2019;45:125-130.

Nurses’ use of conscientious objection and the implications for conscience

Christina Lamb, Marilyn Evans, Yolanad Babenko-Mould, Carol Wong, Ken Kirkwood

Absract
Aims: To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice. Design: Interpretive phenomenology was used to guide this study.

Data sources: Data were collected from 2016 ‐ 2017 through one‐on‐one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings. Review methods: Iterative, phased analysis using line‐by‐line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO.

Impact: This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses’ conscience rights are indicated to address nurses’ conscience issues in practice settings.

Results: Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses’ conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice.

Conclusion: Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience‐based COs.

Lamb C, Evans M, Babenko-Mould Y, Wong C, Kirkwood Ken. Nurses’ use of conscientious objection and the implications for conscience. J Adv Nurs 2018 Oct 16. doi: 10.1111/jan.13869

L’euthanasie au Canada: une mise en garde

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott

Extract
Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français

Euthanasia in Canada: a Cautionary Tale

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

Extract
We are Canadian physicians who are dismayed and concerned by the impact – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . .

Leiva R, Cottle MM, Ferrier C, Harding SR, Lau T, Scott JF. Euthanasia in Canada: A Cautionary Tale. WMJ 2018 Sep; 64:3 17-23.

Medical Assistance in Dying at a paediatric hospital

Carey DeMichelis, Randi Zlotnik Shaul, Adam Rapoport

Abstract
This article explores the ethical challenges of providing Medical Assistance in Dying (MAID) in a paediatric setting. More specifically, we focus on the theoretical questions that came to light when we were asked to develop a policy for responding to MAID requests at our tertiary paediatric institution. We illuminate a central point of conceptual confusion about the nature of MAID that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the ethical challenges of building policy on what is still an extremely controversial social practice. While MAID is currently available to capable patients in Canada who are 18 years or older—a small but important subsection of the population our hospital serves—we write our policy with an eye to the near future when capable young people may gain access to MAID. We propose that an opportunity exists for MAID-providing institutions to reduce social stigma surrounding this practice, but not without potentially serious consequences for practitioners and institutions themselves. Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the issues and questions encountered in this work.

DeMichelis C, Zlotnik Shaul R, Rapoport A. Medical Assistance in Dying at a paediatric hospital. J Med Ethics 2019;45:60-67.

Reasons for requesting medical assistance in dying

Ellen Wiebe, Jessica Shaw, Stefanie Green, Konia Trouton, Michaela Kelly

Abstract
Objective To review the charts of people who requested medical assistance in dying (MAID) to examine their reasons for the request.

Design
Retrospective chart survey.

Setting
British Columbia.

Participants
Patients who requested an assisted death and were assessed by 1 of 6 physicians in British Columbia during 2016.

Main outcome measures
Patients’ diagnoses and reasons for requesting MAID.

Results
Data were collected from 250 assessments for MAID: 112 of the patients had assisted deaths, 11 had natural deaths, 35 were assessed as not eligible for MAID, and most of the rest were not ready. For people who had assisted deaths, disease-related symptoms were given as the first or second most important reason for requesting assisted death by 67 people (59.8%), while 59 (52.7%) gave loss of autonomy, 55 (49.1%) gave loss of ability to enjoy activities, and 27 (24.1%) gave fear of future suffering. People who were assessed as eligible but who had not received assisted deaths were more likely to list fear of future suffering (33.7% vs 7.1%) and less likely to list disease-related symptoms (17.4% vs 40.2%) than those who received MAID were. There was a difference in reasons for MAID given by people with different diagnoses; disease-related symptoms were given as the most important reason by 39.0% of patients with malignancies, 6.8% of patients with neurological diseases, and 28.9% of patients with end-organ failure. Loss of autonomy was given as the most important reason by 16.0% of patients with malignancies, 36.4% of patients with neurological diseases, and 23.7% of patients with end-organ failure.

Conclusion
This study shows that the reasons patients give for requesting an assisted death are similar to those reported in other jurisdictions with similar laws, but in different proportions. Loss of autonomy and loss of ability to enjoy activities were less common reasons among patients in this study compared with other jurisdictions. This might be related to the method of data collection, as in this study, the patients’ reasons were recorded by physicians.

Wiebe E, Shaw J, Green S, Trouton K, Kelly M. Reasons for requesting medical assistance in dying. Can Fam Physician. 2018 Sep;64(674-679.

Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands

Damiaan Denys

Author Summary
A 42-year-old married woman with three children was referred to our department for treatment of treatment-resistant depression. Pharmacotherapy, psychotherapy, and ECT were unsuccessful. We applied deep brain stimulation, which was partially effective and reduced depressive symptoms by 30%, but the patient still suffered. During our struggle to find optimal deep brain stimulation parameters in the course of treatment, the patient requested that her general physician provide euthanasia. Following guidelines in the Netherlands, our team was consulted, but we disapproved because her suffering was not prospectless and there still were treatment options with deep brain stimulation. Although we had treated her intensively for 2 years, our advice was disregarded. Eight weeks later we received the obituary of the patient.

Denys D. Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands. Am J Psychiatry. 2018 Sep 1;175(9):822-823. doi: 10.1176/appi.ajp.2018.18060725.

Providing medical assistance in dying: Practice perspectives

Jessica Shaw, Ellen Wiebe, Amelia Nuhn, Sheila Holmes, Michaela Kelly, Alanna Just

Abstract
Objective: To explore the experiences of the first cohort of physicians to offer medical assistance in dying (MAID) in British Columbia. DESIGN: Qualitative study using semistructured, one-on-one interviews.

Setting: British Columbia.

Participants: Eight physicians who offered MAID in British Columbia in 2016. METHODS: The physicians were interviewed by telephone or by e-mail between 4 and 6 months after MAID was made legal in Canada, with follow-up in January 2017. Interviews were audiorecorded, transcribed, and analyzed through qualitative thematic analysis.

Main Findings: Participants believed that MAID was rewarding and satisfying work. They explained that some of the structural and emotional challenges related to providing MAID included the following: the refusal of faith-based institutions to provide information about MAID to patients, as well as their refusal to allow assessments or deaths to occur on site; having to deny MAID to patients who did not qualify for it; disagreements with colleagues who did not support the provision of MAID; dealing with the grief of family and friends who were present at the death; and feeling like they were always on call. While a few participants thought that the legislative restrictions of Bill C-14 were appropriate in the beginning when MAID was first available in Canada, most would like to see changes to the legislation to make it more aligned with the intent of the Carter decision, including broadening the eligibility criteria to include mature minors and people with advanced psychiatric diagnoses, having the ability to honour advance directives, and removing the requirement of death being in the reasonably foreseeable future for patients with grievous and irremediable conditions.

Conclusion: Physicians in this study explained that providing MAID is rewarding work; however, there are many challenges that complicate their ability to offer MAID to patients. The current MAID legislation in Canada should be updated to better serve the needs of patients.

Shaw J, Wiebe E, Nuhn A, Holmes S, Kelly M, Just A. Providing medical assistance in dying: Practice perspectives. Can Fam Physician. 2018 Sep;64(9):e394-e399.

What the Doctor Ordered: Balancing Religion and Patient Rights in U.S. Pharmacies

Rachel T Caudel

Extract
Conclusion
. . . A statute that requires pharmacies to select their own policies regarding contraceptives and sexual health medication, to publish that policy, and to be required to adhere to the stated policy, however, is a near perfect solution to the delicate balance of protected rights. With cooperation from physicians and compliance within the pharmacies, women will be able to access the pharmaceuticals prescribed to them without delay, hassle, misinformation, or shame. Women will be able to find a pharmacist who will allow them to exercise their choice to use or not to use contraceptives. Pharmacists, on the other hand, will more easily schedule their careers to line up with their moral and religious convictions. A pharmacist will easily be able to determine a pharmacy’s policy on sexual health medications and contraceptives and therefore more easily find employment with a pharmacy that shares his value system. An individualized sexual health medication policy, when accompanied by a directory program, policy publication and compliance supervision, is the best, and possibly only method of insuring all rights at stake are protected.

Caudel RT. What the Doctor Ordered: Balancing Religion and Patient Rights in U.S. Pharmacies. Ky Law J. 2018 Aug;97(3):521-539.