In recent years a large empirical literature has appeared on suffering at the end of life. In this literature it is recognized that suffering has existential and social dimensions in addition to physical and psychological ones. The non-physical aspects of suffering, however, are still understood as pathological symptoms, to be reduced by therapeutical interventions as much as possible. But suffering itself and the negative emotional states it consists of are intentional states of mind which, as such, make cognitive claims: they (...) are more or less appropriate responses to the actual circumstances of the patient. These circumstances often are such that it would rather be a pathological symptom not to be sad and not to suffer. Suffering, therefore, is sometimes and to some extent a condition to be respected. Although I do not dispute that the alleviation of suffering is the main aim of palliative care, in pursuing that aim we should acknowledge a constraint of realism. (shrink)

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The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death (...) can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty. (shrink)

Opt-out systems of postmortem organ procurement are often supposed to be justifiable by presumed consent, but this justification turns out to depend on a mistaken mental state conception of consent. A promising alternative justification appeals to the analogical situation that occurs when an emergency decision has to be made about medical treatment for a patient who is unable to give or withhold his consent. In such cases, the decision should be made in the best interests of the patient. The analogous (...) suggestion to be considered, then, is, if the potential donor has not registered either his willingness or his refusal to donate, the probabilities that he would or would not have preferred the removal of his organs need to be weighed. And in some actual cases the probability of the first alternative may be greater. This article considers whether the analogy to which this argument appeals is cogent, and concludes that there are important differences between the emergency and the organ removal cases, both as regards the nature of the interests involved and the nature of the right not to be treated without one’s consent. Rather, if opt-out systems are to be justified, the needs of patients with organ failure and/or the possibility of tacit consent should be considered. (shrink)

Bei der „terminalen Sedierung“ wird ein unheilbar kranker und schwer leidender Patient für den Rest seines Lebens in ein tiefes Koma versetzt. Das hierzu verwendete Morphin bzw. Midazolam kann lebensverkürzend wirken. Ist dies also eine Maßnahme, die das Leben des Patienten beendet, auf seinen Wunsch hin oder nicht? Gewöhnlich wird diese Frage mit nein beantwortet, wenn die lebensverkürzende Wirkung nur vorhersehbar, aber nicht beabsichtigt ist. Allerdings ist der Zugang der Menschen auch zu ihren eigenen Intentionen fallibel, so dass sogar ihre (...) Selbstangaben in komplexen Fällen nicht sehr zuverlässig sind. Wenn ein Arzt sagt, dass er „beabsichtigt“, das Leben eines Patienten zu verkürzen, meint er damit möglicherweise nur, dass dieses vorhersehbare Ergebnis ein erwünschtes ist. Diese Art der Einschätzung kann nicht als solche moralisch diskreditiert werden, weil sie bei anderen allgemein akzeptierten Entscheidungen unvermeidlich ist, z. B. von einer „vergeblichen“ Behandlung Abstand zu nehmen. Legitimerweise können wir von einem Fachmann erwarten, dass er begründet handelt. Deshalb sollte unsere Klassifikation von ärztlichem Handeln als „terminale Sedierung“ oder „Beendigung des Lebens des Patienten“ nicht von den Intentionen des Arztes abhängen, sondern von den in dieser speziellen Krankheitsphase bei diesem speziellen Patienten verwendeten Dosierungen. (shrink)

This paper argues, against Pettit’s thesis about the incorporation of responsibility, that holding collective agents criminally responsible is necessarily either redundant or unfair: redundant if responsibility can be distributed without remainder over individual persons; unfair if it cannot. It should be the task of legal systems to create chains of individual criminal responsibility encompassing executives, officials, and members of corporate agents.

When the decision has been made to stop treatment of a newborn child with a bad prognosis, the child usually dies in a short time. Sometimes, however, gasping occurs, and although it is usually thought that this is not a sign of suffering, the parents can hardly fail to interpret it as such. Could that be a reason to administer muscle relaxants to the child? It would not harm the child and may greatly benefit the parents. So it seems the (...) humane thing to do. Legally, however, the action would count as killing, and the prohibition of killing normally implies a denial of the authority to decide on exceptions, which should be understood as a protection of public trust. I discuss three ways of arguing why the law, nevertheless, should allow for an exception in this case. The discussion identifies and describes this kind of conflict, and shows how to evaluate proposals for solving it, using a particularly clear exemplary case by way of illustration. (shrink)

In 2015 Robert Veatch published the second edition of his Transplantation ethics, this time together with Lainie Ross. The chapters on postmortem organ procurement distinguish between ‘giving’ and ‘taking’ systems, and argue that ‘taking’ systems may promise a greater yield of organs for transplantation, but inevitably violate a requirement of respect for the deceased's autonomy. That argument has been very influential, and is also representative of a way of thinking that is widespread in the literature and in public debate. In (...) this paper I contend that it is conceptually flawed in a number of important respects. These concern the understanding of both the concept of ‘consent’ and the requirement of respect for autonomy, the role of the relatives in any procurement system, and the factors that actually determine the extent to which a system respects autonomy, under any interpretation of that requirement. (shrink)