Protection of Conscience Project Library

Palliative care professionals’ willingness to perform euthanasia or physician assisted suicide

Julia Zenz, Michael Tryba, Michael Zenz

Abstract
Background: Euthanasia and physician assisted suicide (PAS) are highly debated upon particularly in the light of medical advancement and an aging society. Little is known about the professionals’ willingness to perform these practices particularly among those engaged in the field of palliative care and pain management. Thus a study was performed among those professionals.

Methods: An anonymous questionnaire was handed out to all participants of a palliative care congress and a pain symposium in 2013. The questionnaire consisted of 8 questions regarding end of life decisions. Proposed patient vignettes were used.

Results: A total of 470 eligible questionnaires were returned, 198 by physicians, 272 by nurses. The response rate was 64 %. The majority of professionals were reluctant to perform euthanasia or PAS: 5.3 % of the respondents would be willing to perform euthanasia on a patient with a terminal illness if asked to do so. The reluctance grew in case of a patient with a non-terminal illness. The respondents were more willing to perform PAS than euthanasia. Nurses were more reluctant to take action as opposed to the physicians. The majority of the respondents would attempt to treat the patient’s symptoms first before considering life-ending measures. As regards any decision making process the majority would consult with a colleague.

Conclusions: This is the first German study to ask about the willingness of professionals to take action as regards euthanasia and PAS without biased phrasing. As opposed to the general acceptance that is respectively high, the actual willingness to perform life-ending measures is low. The German debate on physician assisted suicide and its possible legalization should also incorporate clarifications regarding the responsibility who should eventually perform these acts.

Zenz J, Tryba M, Zenz M. Palliative care professionals’ willingness to perform euthanasia or physician assisted suicide. BMC Palliative Care. 2015 Nov 14;14(1).

“Conscientious Objection” in Reproductive Healthcare is Immoral and Should Be Abolished

Joyce H Arthur

Extract
The majority of so-called “conscientious objection” is exercised today in reproductive healthcare and is not really about protecting the right to conscience. It’s about a person in a privileged position of authority (there by choice) imposing their personal beliefs on a vulnerable other in a dependent position (not there by choice).

Arthur JH. “Conscientious Objection” in Reproductive Healthcare is Immoral and Should Be Abolished. Joyce Arthur Blog. 2015.

A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands

Marianne C Snijdewind, Dick L Willems, Luc Deliens, Bregje D Onwuteaka-Philipsen, Kenneth Chambaere

Abstract
Importance: Right to Die NL, an organization in the Netherlands that advocates for the option of euthanasia, founded the End-of-Life Clinic in 2012 to provide euthanasia or physician-assisted suicide for patients who meet all legal requirements but whose regular physicians rejected their request. Many patients whose requests are rejected have less common situations, such as a psychiatric or psychological condition, dementia, or being tired of living.

Objective: To study outcomes of requests for euthanasia or physician-assisted suicide received by the clinic and factors associated with granting or rejecting requests.

Design: Analysis of application forms and registration files from March 1, 2012, to March 1, 2013, the clinic’s first year of operation, for 645 patients who applied to the clinic with a request for euthanasia or physician-assisted suicide and whose cases were concluded during the study period. Main Outcomes and

Measures: A request could be granted, rejected, or withdrawn or the patient could have died before a final decision was reached. We analyzed bivariate and multivariate associations with medical conditions, type of suffering, and sociodemographic variables.

Results: Of the 645 requests made by patients, 162 requests (25.1%) were granted, 300 requests (46.5%) were refused, 124 patients (19.2%) died before the request could be assessed, and 59 patients (9.1%) withdrew their requests. Patients with a somatic condition (113 of 344 [32.8%]) or with cognitive decline (21 of 56 [37.5%]) had the highest percentage of granted requests. Patients with a psychological condition had the smallest percentage of granted requests. Six (5.0%) of 121 requests from patients with a psychological condition were granted, as were 11 (27.5%) of 40 requests from patients who were tired of living.

Conclusions and Relevance: Physicians in the Netherlands have more reservations about less common reasons that patients request euthanasia and physician-assisted suicide, such as psychological conditions and being tired of living, than the medical staff working for the End-of-Life Clinic. The physicians and nurses employed by the clinic, however, often confirmed the assessment of the physician who previously cared for the patient; they rejected nearly half of the requests for euthanasia and physician-assisted suicide, possibly because the legal due care criteria had not been met.

Snijdewind MC, Willems DL, Deliens L, Onwuteaka-Philipsen BD, Chambaere K. A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Internal Medicine. 2015 Oct;175(10):1633-1640.

Conscience and Complicity: Assessing Pleas for Religious Exemptions in Hobby Lobby’s Wake

Amy J Sepinwall

Abstract
In the paradigmatic case of conscientious objection, the objector claims that his religion forbids him from actively participating in a wrong (for example, by fighting in a war). In the religious challenges to the Affordable Care Act’s employer mandate, on the other hand, employers claim that their religious convictions forbid them from merely subsidizing insurance through which their employees might commit a wrong (for example, by using contraception). The understanding of complicity underpinning these challenges is vastly more expansive than the standard that legal doctrine or moral theory contemplates. Courts routinely reject claims of conscientious objection to taxes that fund military initiatives or to university fees that support abortion services. In Hobby Lobby, however, the Supreme Court took the corporate owners at their word: the mere fact that Hobby Lobby believed that it would be complicit, no matter how idiosyncratic its belief, sufficed to qualify it for an exemption. In this way, the Court made elements of an employee’s health-care package the “boss’s business” (to borrow from the nickname of the Democrats’ proposed bill to overturn Hobby Lobby).

Much of the critical reaction to Hobby Lobby focuses on the issue of corporate rights of religious freedom. Yet this issue is a red herring. The deeper concerns that Hobby Lobby raises—about whether employers may now refuse, on religious grounds, to subsidize other forms of health coverage (for example, blood transfusions or vaccinations) or to serve customers whose lifestyles they deplore (for example, gays and lesbians)—do not turn on the organizational form that the employer has adopted. Instead, the more significant issue goes to our understanding of complicity: When is it reasonable for an employer (for-profit or nonprofit, corporate or individual) to think itself complicit in the conduct of its employees or customers? And when is a reasonable claim of complicity compelling enough to warrant an accommodation, especially when that accommodation would impose costs on third parties?

Sepinwall AJ. Conscience and Complicity: Assessing Pleas for Religious Exemptions in Hobby Lobby’s Wake. U Chicago Law Rev. 2015 Fall; 82:1897-1980.

An argument for physician-assisted suicide and against euthanasia

Raphael Cohen-Almagor

Abstract
The article opens with the hypothesis that the default position that should guide healthcare providers when treating patients at the end-of-life is that patients opt for life. In the absence of an explicit request to die, we may assume that patients wish to continue living. Thus, the role of the medical profession is to provide patients with the best possible conditions for continued living. The article makes a case for physician-assisted suicide legislation. It examines the ‘quality-of-life’ argument, and the issue of the patient’s autonomy and competence. It is argued that (1) quality-of-life is a subjective concept. Only the patient can conclude for herself that her quality-of-life is so low to warrant ending it, and that (2) only competent patients may request ending their lives. Patients’ lives should not be actively terminated by the medical team without the explicit consent of patients. The article then probes the role of physicians at the end-of-life, arguing that medicine should strive to cater to the wishes of all patients, not only the majority of them. Physicians should not turn their backs to justified requests by their patients. Physicians are best equipped to come to the help of patients at all stages of their illness, including their end-of-life. At the same time, in ending life, the final control mechanism should be with the patient. Thus, physician-assisted suicide is preferred to euthanasia in order to lower the possibility of abuse and of ending the lives of patients without their consent and against their wishes. As matters of life and death are grave, they should be taken with utmost seriousness, requiring the instalment of ample checks against abuse and facilitating mechanisms designed to serve the patient’s best interests. The article concludes with 19 careful and detailed guidelines for physician-assisted suicide. These are necessary measures designed to ensure that the best interests of the patients are served as they wished.

Cohen-Almagor R. An argument for physician-assisted suicide and against euthanasia. Ethics Med Pub Health. 2015 Oct;1(4):431-441.

Multi-fetal Pregnancy Reduction in Assisted Reproductive Technologies: A License to Kill?

Siddharth Khanijou

Extract
Conclusion
The objective of this Article is not to make a case that multifetal pregnancy reduction should be banned. . . . The procreational autonomy bestowed by the Constitution cannot be extended to permit the unbridled, willful creation and destruction of fetuses. Autonomy does not grant society a license to absolute freedom from intervention in all matters regarding our reproductive capacity. . . .

Assisted reproductive technologies, like other medical technologies, do not exist in a vacuum. The potential economic and social harms that may result from irresponsible practice extend beyond the ART participants. . . . In an era where government silence equals acquiescence and where unregulated technology threatens to devalue humanity, political stalemate is not a valid excuse. Proactive federal oversight is central to cure the problems created over the past twenty- five years by the lack of regulation over ART.

Khanijou S. Multi-fetal Pregnancy Reduction in Assisted Reproductive Technologies: A License to Kill? DePaul J Health Care Law. 2005 Oct;8(2):403-430.

(Thesis) A Region at Odds: Abortion Politics in the Maritime Provinces, 1969-1988

Katrina Ackerman

Abstract
The inaccessibility of abortion services in the Maritime Provinces remains a constant topic in the media, and yet little research has been conducted to explain the barriers to the procedure in the region. Despite many excellent studies on the barriers enforced at a provincial level after the Supreme Court of Canada case R. v. Morgentaler (1988), which decriminalized abortion nationwide, few studies provide insight into to the reasoning for strong opposition to abortion access in the region. This dissertation endeavours to fill this gap in the scholarship through a historical analysis of abortion politics in the Maritime Provinces between 1969 and 1988. When the federal government liberalized the abortion law in 1969 at the behest of the women’s movement, Canadian Bar Association, and Canadian Medical Association, opposition to the medical procedure came to the forefront. Medical professionals, politicians, clergy, and citizens quickly united to form pro-life organizations and became a powerful countermovement in the region. Through an exploration of medical society, government, and social movement organization records in conjunction with interviews with residents, this dissertation offers insight into the effectiveness and longevity of pro-life activism in New Brunswick, Nova Scotia, and Prince Edward Island. Furthermore, it illuminates the financial, physical, and psychological costs of attempting to terminate pregnancies in the region.

Ackerman K. (Thesis) A Region at Odds: Abortion Politics in the Maritime Provinces, 1969-1988. 2015.

Fetal Tissue Fallout

R Alta Charo

New England Journal of Medicine, NEJM — New England Journal of Medicine

Abstract
The duty of care is a fundamental principle of medicine that should be at the heart of the debate surrounding Planned Parenthood and fetal tissue research. And that duty includes taking advantage of avenues of hope for current and future patients.

Charo RA. Fetal Tissue Fallout. N Engl J Med. 2015 Sep 03;373(10):890-891. Available from:

The Irish experience of Symphysiotomy: 40 Years onwards

SR Shaarani, W Van Eeden, JM O’Byrne

Abstract
The art of symphysiotomy for delivery in the instance of cephalopelvic disproportion has been a dying art since the advent of caesarean section but in Ireland this surgical procedure was not abolished until 1992. This practice is still present in the developing world and in some circumstances used in developed countries. This study offers some insights on the 40-year follow-up of patients who had undergone symphysiotomy.

Shaarani S, Eeden WV, O’Byrne J. The Irish experience of Symphysiotomy: 40 Years onwards. J Obstet Gynaecol. 2016;36(1):48-52; online 2015-07-27.

Tasmania’s Reproductive Health (Access to Terminations) Act 2013: An analysis of conscientious objection to abortion and the “obligation to refer”

Ronli Sifris

Abstract
This article focuses on Tasmania’s Reproductive Health (Access to Terminations) Act 2013, which decriminalises abortion in that State. The article first provides an overview of the Tasmanian legislation, comparing it with Victoria’s Abortion Law Reform Act 2008. It then provides a more in-depth analysis of a doctor’s right to “conscientious objection” and the requirement in both Acts of an “obligation to refer”. The article concludes that ultimately, as a democratic society, it is important that both a woman’s right to terminate a pregnancy and a doctor’s right to freedom of conscience is respected. Where these rights conflict, as is the case when a doctor with a conscientious objection to abortion is confronted with a patient who seeks information about abortion, they must be balanced. The Victorian and Tasmanian Acts represent a considered and reasonable approach to balancing the rights at issue.

Sifris R. Tasmania’s Reproductive Health (Access to Terminations) Act 2013: An analysis of conscientious objection to abortion and the “obligation to refer”. J Law Med. 2015 Jul;22(4):900-914.