Assisted suicide Archives - Page 7 of 11 - Protection of Conscience Project Library

The right to die and the medical cartel

M Cholbi

Abstract
Advocates of a right to die increasingly assert that the right in question is a positive right (a right to assistance in dying) and that the right in question is held against physicians or the medical community. Physician organizations often reply that these claims to a positive right to die should be rejected on the grounds that medicine’s aims or “internal” norms preclude physicians from killing patients or assisting their patients in killing themselves. The aim of this article is to rebut this reply. Rather than casting doubt on whether assisted dying is consistent with medicine’s “internal” norms, I draw attention to the socioeconomic contexts in which contemporary medicine is practiced. Specifically, contemporary medicine typically functions as a public cartel, one implication of which is that physicians enjoy a monopoly on the most desirable life-ending technologies (fast acting lethal sedatives, etc). While there may be defensible public health reasons for medicine functioning as a cartel and having this monopoly on desirable life-ending technologies, Rawlsian contract-based reasoning illustrates that the status of medicine as a cartel cannot be reconciled with its denying the public access to supervised use of desirable life-ending technologies. The ability to die in ways that reflect one’s conception of the good is arguably a primary social good, a good that individuals have reasons to want, whatever else they may want. Individuals behind Rawls’ veil of ignorance, unaware of their health status, values, etc, will thus reason that they may well have a reasonable desire for the life-ending technologies the medical cartel currently monopolizes. They thus have reasons to endorse a positive right to physician assistance in dying. On the assumption that access to desirable life-ending technologies will be controlled by the medical community, a just society does not permit that community to deny patients access to these technologies by an appeal to medicine’s putative “internal” aims or norms. The most natural response to my Rawlsian argument is to suggest that it only shows that individuals have a positive right against the medical community to access life-ending technologies but not a right to access such technologies from individual physicians. Individual physicians could still refuse to provide such technologies as a matter of moral conscience. Such claims of conscience should be rejected, however. A first difficulty with this proposal is that it is in principle possible for a sufficiently large number of individuals within a profession to invoke claims of conscience so as to materially hinder individuals from exercising their positive right to die, as appears to be the case in several jurisdictions with respect to abortion and other reproductive health treatments. Second, unlike conscientious objectors to military service, physicians who conscientiously object to providing assistance in dying would not be subject to fundamental deprivations of rights if they refused to provide assistance. Physicians who deny patients access to these technologies use their monopoly position in the service of a kind of moral paternalism, hoarding a public resource with which they have been entrusted so as to promote their own conception of the good over that of their patients.

Cholbi M. The right to die and the medical cartel. Ethics Med Pub Health. 2015 Nov 19;1(4):486-493.

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).

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.

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.

Unanimity on Death with Dignity — Legalizing Physician-Assisted Dying in Canada

Amir Attaran

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

Extract
In February 2015, Canada legalized physician-assisted dying — a first among countries with common-law systems, in which law is often developed by judges through case decisions and precedent. The Supreme Court of Canada issued the decision in Carter v. Canada, and its reasoning and implications for clinical practice bear examination.

Attaran A. Unanimity on Death with Dignity — Legalizing Physician-Assisted Dying in Canada. N Engl J Med. 2015;372(22):2080-2082.

Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium

Kenneth Chambaere, Robert Vander Stichele, Freddy Mortier, Joachim Cohen, Luc Deliens

Extract
We found an increased demand for euthanasia in Belgium between 2007 and 2013, as well as growing willingness among physicians to meet those requests, mostly after the involvement of palliative care services. This finding indicates that, after 11 years of experience, euthanasia is increasingly considered as a valid option at the end of life in Belgium.

Chambaere K, Stichele RV, Mortier F, Cohen J, Deliens L. Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium. N Engl J Med. 2015 Mar 19;372(12):1179-1181.

The law and physician-assisted dying

Tom Koch

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

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.

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

Jan L. Bernheim, Wim Distelmans, Arsène Mullie, Michael A. Ashby

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.

Canadian physicians warned to get ready for euthanasia and assisted suicide

Sean Murphy

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.

Dignity, death, and dilemmas: A study of Washington hospices and physician-assisted death

Courtney S. Campbell, Margaret A. Black

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]