What would make it the right time for you to die, or the wrong one? In particular, could it be the right time for you to die even if your loved ones want to make the sacrifices needed to prolong your life, because that would cost them too dearly? The worry is that it would be selfish to permit these sacrifies, and wrong for that reason. I think it matters that the sacrifies would occur within a relationship of mutual devotion, (...) and I try to say how it matters. In particular, I argue against some fairly simple views of what constitutes impermissible selfishness in this context, and in favor of approaching such decisions in a different way. (shrink)

The right to die has for decades been recognised for persons in a vegetative state, but there remains controversy about ending life-sustaining medical treatment for persons in the minimally conscious state. The controversy is rooted in assumptions about the moral significance of consciousness, and the value of life for patients who are conscious and not terminally ill. This paper evaluates these assumptions in light of evidence that generates concerns about quality of life in the MCS. It is argued that surrogates (...) should be permitted to make decisions to withdraw life-sustaining medical treatment from patients in the MCS. (shrink)

The article discusses the way people wish to die, analyzing the legal situation in countries that permit either euthanasia or physician-assisted suicide. While criticizing the Dutch, Belgian and Swiss models, I argue that the Oregon model is the one with apparently little abuse. Building on the experiences of Oregon, the Netherlands, Belgium, Switzerland, and the Northern Territory of Australia, the article ends with a set of guidelines to improve the conduct of PAS.

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine’s distinction between (...) martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent’s actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments. (shrink)

Even in the Netherlands, where the practice of physician-assisted death (PAD) has been legalized for over 20 years, there is no such thing as a ‘right to die’. Especially patients with extraordinary requests, such as a wish for PAD based on psychiatric suffering, advanced dementia, or (a limited number of) multiple geriatric syndromes, encounter barriers in access to PAD. In this paper, we discuss whether these barriers can be justified in the context of the Dutch situation where PAD is legally (...) permitted for those who suffer unbearably and hopelessly as a result of medical conditions. Furthermore, we explore whether there are options to address some of the barriers or their consequences, both within the Dutch legal framework or by adjusting the legal framework, and whether these options are feasible. We conclude that although there are insufficient arguments to overrule the doctor’s freedom of conscience in the Netherlands, there are ways to address some of the barriers, mainly by offering support to doctors that would be willing to support a request. Moreover, we believe it is morally required to reduce or mitigate where possible the negative consequences of the barriers for patients, such as the long waiting time for those who suffer from psychiatric disorders, because it is unlikely the adjustments suggested to the system will ensure reasonable access for these patient groups. (shrink)

Decisions regarding the end-of-life of minor patients are amongst the most difficult areas of decision-making in pediatric health care. In this field of medicine, such decisions inevitably occur early in human life, which makes one aware of the fact that any life—young or old—cannot escape its temporal nature. Belgium and the Netherlands have adopted domestic regulations, which conditionally permit euthanasia and physician-assisted suicide in minors who experience hopeless and unbearable suffering. One of these conditions states that the minor involved must (...) be legally competent and able to express an authentic and lasting wish to die. This contribution is different from other legal texts on end-of-life decisions in modern health care. Foremost, it deals with the role time-bound components play in our views on the permissibility of such decisions with regard to minor patients. While other disciplines provide profound reflections on this issue, from a legal point of view this side has hardly been explored, let alone examined with regard to its relevance for the legal permissibility of end-of-life decisions in pediatrics. Therefore, the manuscript inquires whether there are legal lessons to be learned if we look more closely to temporality-related aspects of these end-of-life decisions, particularly in connection to a minor patient’s assumable ability to choose death over an agonizing existence. (shrink)

While eleven U.S. jurisdictions have authorized medical aid in dying (MAID), it remains inaccessible to terminally ill patients who have physical disabilities that make them unable to complete self...

Introduction This paper defends the moral significance of the distinction between killing and letting die. In the first part of the paper, I consider and reject Michael Tooley’s argument that initiating a causal process is morally equivalent to refraining from interfering in that process. The second part disputes Tooley’s suggestion it is merely external factors that make killing appear to be worse than letting die, when in reality the distinction is morally neutral. Tooley is mistaken to claim that we are (...) permitted to kill bystanders who had no fair chance to avoid being at risk of harm. We can support the significance of the killing / letting die distinction by considering the difference between what we are permitted to do in self-defence against those who are going to kill us, and what we can do against those who are going to let us die. I also suggest that we are less responsible for the deaths we allow than for the deaths that we cause, since we do not make people worse off for our presence in cases where we fail to save them. (shrink)

Medical assistance in dying has received considerable attention from many in the field of bioethics. Philosophers, theologians, lawyers, and clinicians of all sorts have engaged with many challenging aspects of this issue. Public debate, public policy, and the law have been enhanced by the varied disciplinary analyses. With the legalization of MAiD in Canada, some attention is now being turned to issues that have historically been overshadowed by the debate about whether to permit MAiD. One such issue is voluntary stopping (...) eating and drinking as an alternative to MAiD. In this paper, I will apply a legal lens to the issue. An understanding of whether VSED is legal provides a foundation for ethical reflection on whether it ought to be permitted. Is it permitted for those who prefer VSED to MAiD? Is it permitted for those who do not qualify for MAiD under our current legislation – for those who do not have a grievous and irremediable medical condition, for mature minors, for individuals whose sole underlying medical condition is a mental disorder and who do not otherwise meet the eligibility criteria, and for individuals who have lost capacity but had completed an advance directive? (shrink)

Medical assistance in dying (MAiD) has received considerable attention from many in the field of bioethics. Philosophers, theologians, lawyers, and clinicians of all sorts have engaged with many challenging aspects of this issue. Public debate, public policy, and the law have been enhanced by the varied disciplinary analyses. With the legalization of MAiD in Canada, some attention is now being turned to issues that have historically been overshadowed by the debate about whether to permit MAiD. One such issue is voluntary (...) stopping eating and drinking (VSED) as an alternative to MAiD. In this paper, I will apply a legal lens to the issue. An understanding of whether VSED is legal provides a foundation for ethical reflection on whether it ought to be permitted. Is it permitted for those who prefer VSED to MAiD? Is it permitted for those who do not qualify for MAiD under our current legislation – for those who do not have a grievous and irremediable medical condition, for mature minors, for individuals whose sole underlying medical condition is a mental disorder and who do not otherwise meet the eligibility criteria, and for individuals who have lost capacity but had completed an advance directive? (shrink)

BackgroundDealing with end of life is challenging for patients and health professionals alike. The situation becomes even more challenging when a patient requests a legally permitted medical service that a health professional is unable to provide due to a conflict of conscience. Such a scenario arises when Victorian health professionals, with a conscientious objection (CO) to voluntary assisted dying (VAD), are presented with patients who request VAD or merely ask about VAD. The Voluntary Assisted Dying Act 2017 (Vic) recognizes the (...) inherent conflict of conscience that may arise for some health professionals when asked to provide VAD and responds by affording broad protection to conscientious objectors who wish to refuse to take part in the VAD process.MethodsSeventeen semi-structured qualitative interviews were conducted with Victorian health professionals with a self-identified CO to VAD in the lead-up to the implementation of VAD in Victoria. Interviews explored how participants anticipated they would manage their CO in practice. Interviews were transcribed verbatim and analyzed thematically.ResultsOur results reveal that the way in which health professionals claimed they would approach CO conversations is variable and was dependant on the strength of their opposition to VAD. We categorized conscientious objectors according to their approach as either dissuasive non-referrers, passive non-referrers, facilitators or negotiators. Our study also explores the perceived difficulties of exercising one’s CO as identified by our participants.ConclusionThe broad protection offered by the Voluntary Assisted Dying Act 2017 (Vic) encourages a range of behaviors from conscientious objectors, due to the minimal obligations imposed. In order to assist conscientious objectors, more policy, institutional guidance, and education needs to be available to conscientious objectors explicitly addressing how to effectively manage one’s CO. Such guidance is imperative to ensuring that their moral integrity is preserved and that they are exercising their CO appropriately. (shrink)

Is it worse to kill someone than to let someone die? It seems obvious to common sense that it is worse. We allow people to die, for example, when we fail to contribute money to famine-relief efforts; but even if we feel somewhat guilty, we do not consider ourselves murderers. Nor do we feel like accessories to murder when we fail to give blood, sign an organ-donor card, or do any of the other things that could save lives. Common sense (...) tells us that, while we may not kill people, our duty to give them aid is much more limited. Some philosophers, however, have argued that common sense is wrong about this. They have defended the Equivalence Thesis, which says that killing and letting die are equally bad. This is a more specific version of the idea that there is no moral difference between making something happen and allowing it to happen. The Equivalence Thesis is a radical conception that would require changes in our ordinary moral beliefs. If it is true, then obviously our duty to give aid is much stronger than we commonly assume. But our views about other matters, such as euthanasia, will also be affected. Many people believe that “passive euthanasia”--allowing terminal patients to die, rather than pointlessly prolonging their lives--is sometimes permissible; but they also believe that killing patients is always wrong. If the Equivalence Thesis is true, this combination of beliefs is inconsistent. The idea behind the Equivalence Thesis is not that every individual case of letting die is equally as bad as every individual case of killing. Obviously, if we compare an ordinary murder--say, a man killing his wife out of jealousy--with the actions of a physician who humanely permits a suffering patient to die, the murder is much worse. Rather, the idea is that the difference between killing and letting die does not itself make a difference to the moral assessment of the actions. Other factors may still be important. (shrink)

Many people hold that there is an important moral distinction between passive euthanasia and active euthanasia. Thus, while the AMA maintains that people have a right quote to die with dignity, quote so that it is morally permissible for a doctor to allow someone to die if that person wants to and is suffering from an incurable illness causing pain that cannot be sufficiently alleviated, the MA is unwilling to countenance active euthanasia for a person who is in similar straits, (...) but who has the misfortune not to be suffering from an illness that will result in a speedy death. -/- A similar distinction with respect to infanticide has become a commonplace of medical thinking and practice. If an infant is a mongoloid or a microcephalic, and happens also to have some other defect requiring corrective surgery if the infant is to live, many doctors and hospitals believe that the parents have the right to decide whether the surgery will be performed, and thus whether the infant will survive. But if the child does not have any other defect, it is believed that the parents do not have the right to terminate its life. -/- The rationale underlying these distinctions between active and passive euthanasia, and between active and passive infanticide, is the same: the idea that there is a crucial moral difference between intentionally killing and intentionally letting die. This idea is admittedly very common. But I believe that it can be shown to reflect either confused thinking or a moral point of view unrelated to the interests of individuals. (shrink)

This article explores at least two dominant critiques of assisted dying from a disability rights perspective. In spite of these critiques, I conclude that assisted dying ought to be permissible. I arrive at the conclusion that if we respect and value people with disabilities, we ought to permit assisted dying. I do so in the following manner. First, I examine recent changes in legislation that have occurred since the Royal Society of Canada Expert Panel on End-of-Life Decision-Making report, published in (...) this journal. I suggest that these changes are likely to only strengthen opposition to assisted dying from disability rights activists and people with disabilities. Second, I focus on respect for people with disabilities and in particular, respect for their autonomy and decision-making abilities. Third, I explore the opposition to assisted dying that focuses on risk and the vulnerability of people with disabilities. Here I suggest that this risk ought not to be of special concern. Ultimately, I conclude that upholding respect for the disabled requires the legalization of assisted dying, rather than the denial of access in a misguided effort to protect people with disabilities. (shrink)

In this chapter, we explore the issue of assisted dying for individuals with dementia at the nexus of ethics and law. We set out the basic medical realities of dementia and the available data about the desire for the option of assisted dying in the face of dementia. We then describe law and practice with respect to voluntary euthanasia and assisted suicide in jurisdictions that permit at least some assisted dying. We conclude that, because of the peculiar ways in which (...) some of the features of dementia interact with specific legislative provisions, less access to assisted dying for persons with dementia can be realized through the legislation than might have been intended or expected. We then describe draft assisted dying legislation that is before the federal Parliament of Canada. We conclude that, because of the peculiar ways in which some of the features of dementia interact with specific legislative provisions, more access to assisted dying for persons with dementia would be realized, if the legislation was passed as drafted, than might be intended or expected. This exercise reveals that very careful attention needs to be paid to the features of dementia if drafting assisted dying legislation in order to actually achieve the desired law reform effect (whatever that might be). The interplay of common ethical rationales for permitting assisted dying (e.g., autonomy and alleviation of suffering) with common features of dementia (e.g., loss of competence before the terminal phase of the illness, loss of the capacity to communicate before the loss of the capacity to suffer) raises challenges for translating one’s ethical position on assisted dying for individuals with dementia into law. NB: This chapter is current up to 2015. (shrink)

A governing principle in medical ethics is respect for patient autonomy. This principle is commonly drawn upon in order to argue for the permissibility of assisted dying. In this paper I explore the proper role that respect for patient autonomy should play in this context. I argue that the role of autonomy is not to identify a patient’s best interests, but instead to act as a side-constraint on action. The surprising conclusion of the paper is that whether or not it (...) is in the best interests for the patient to die is a morally objective matter. This allows for the possibility that it can be in the best interests of the patient to die even if she autonomously considers it to be in her best interest to continue living. I argue that concerns about ‘mandatory’ euthanasia can be met when patient autonomy is respected as a side-constraint on action. Ultimately, this means that assisted dying is permissible, not because the autonomous patient views her suffering to be unbearable, but because it is in her objective best interests and she permitted it via her consent. (shrink)

In this brief paper, a case is made for the moral permissibility of assisted dying. The paper proceeds by highlighting a common critique from within disability rights scholarship and advocacy that emphasizes the vulnerability of people with disabilities and the risks associated with permitting assisted dying. The paper suggests that because medicine necessarily involves risk, primarily through the high likelihood of medical error, that the risk and harm being utilized as a justification to prohibit assisted dying by disability rights (...) scholars is in fact, not conceptually or morally unique. Finally, it is argued that because all medicine involves a risk of harm, and assisted dying is not unique in this respect, that one cannot effectively launch a critique of assisted dying on this basis. (shrink)

In diesem Beitrag werde ich die Wege untersuchen, auf denen Moraltheoretiker philosophischen Sinn in der These entdecken könnten, daß das Gesetz die moralische Schlechtigkeit von Personen dadurch tolerieren sollte, daß es den Bürgern Rechte zuerkennt, moralisch Falsches zu tun. Dabei vernachlässige ich Fälle, in denen diese Toleranz deshalb angemessen erscheint, weil die Moralität des in Rede stehenden Verhaltens ungewiss oder jedenfalls unter gleichermaßen vernünftigen Personen hinreichend umstritten ist, so daß die Gewährung von Freiheit auch für den Staat als das angemessene (...) Mittel erscheint, die Problematik zu lösen. Stattdessen werde ich mich auf Fälle konzentrieren, in denen der Gesetzgeber davon überzeugt ist, daß das betreffende Verhalten tadelnswert ist, so daß weder Zweifel noch Uneinigkeit über die Bewertung des Verhaltens als ausreichende Gründe dafür genannt werden können, daß der Staat sich der Sache nicht annimmt.Wie ich im 1. Teil zeige, kann sowohl von konsequentialistischen als auch von deontologischen Moraltheorien angenommen werden, daß sie unmoralisches Verhalten erlauben, das keine Verletzung von konsequentialistischen bzw. deontologischen Pflichten darstellt. Regel-Konsequentialisten verlangen Toleranz für akt-konsequentialistisch betrachtete Verstöße, sofern sie im Rahmen ihrer Regeln erfolgen; und Deontologen fordern Toleranz für kategorisch erlaubte Taten, die sub-optimale Konsequenzen haben. Im Hinblick darauf, daß wir eine Tugenpflicht haben könnten, uns zu Personen zu entwickeln, die deontologische Erlaubnisse nicht mißbrauchen, untersuche ich eine Reihe von Gründen, die es nahe legen, daß diejenigen, die sich einer Moraltheorie der Tugendpflichten verbunden fühlen, die die Besorgnis um Handlungen durch eine Besorgnis um den Charakter der Person ersetzt, gleichwohl gute Gründe dafür hat, die Kultivierung eines guten Charakters außerhalb der Reichweite des Staates zu belassen.Die Problematik wird schwieriger, wenn wir von den unmoralischen Handlungen, die keine Pflichten verletzen , zu den unmoralischen Handlungen übergehen, die solche Pflichten verletzen. Kann ein Konsequentialist sich damit einverstanden erklären, daß der Staat Personen die Freiheit zugesteht, etwas zu tun, was konsequentialistisch verboten ist? Kann ein Deontologe nicht nur die Freiheit, Erlaubnisse zu missbrauchen, verteidigen, sondern auch die Freiheit, kategorische Verbote zu verletzen? Im 2. Teil des vorliegenden Beitrages vertrete ich die These, daß es durchaus einleuchtende Gründe dafür geben mag, daß Freiheit entweder intrinsisch oder instrumentell gut ist, um andere intrinsisch gute Dinge zu bewirken, in welchem Fall Konsequentialisten gute Gründe dafür haben, daß der Staat grundsätzlich moralische Schlechtigkeit tolerieren sollte, oder sie zumindest dann tolerieren sollte, wenn dies der Preis dafür ist, größeres Gutes zu befördern. Im 3. Teil behaupte ich, daß selbst unsere beste deontologische Theorie Maximen in sich aufnehmen kann, die es dem Gesetzgeber kategorisch verbieten, den Bürgern die Verletzung kategorischer Maximen zu verbieten. So kann es dem Gesetzgeber z.B. verboten sein, in die Privatsphäre der Bürger einzugreifen, um das Fehlverhalten von Bürgern zu ermitteln. Oder es kann dem Gesetzgeber auferlegt sein, nicht etwas zu verbieten, wenn er dieses Verbot nicht gegenüber allen Bürgern durchsetzen kann.Das Ergebnis meiner Analyse ist, daß die Theorie liberaler Toleranz nicht von der Behauptung vernünftigen Zweifels und der Uneinigkeit zwischen Gesetzgeber und Bürgern abhängt, wie es unter liberalen Politikwissenschaftlern oftmals voraus-gesetzt wird. Selbst dann, wenn vernünftige Personen sich darüber einig sind, daß eine bestimmte Art von Verhalten unmoralisch ist, und selbst dann, wenn bei dem Gesetzgeber kaum Zweifel an der Unmoralität des Verhaltens vorhanden sind, gibt es doch schwerwiegende moralische Gründe dafür, weshalb der Gesetzgeber moralisch verpflichtet sein kann, die Begehung unmoralischer Handlungen zu tolerieren. In this article I explore the ways in which moral theorists might make philosophical sense of the claim that the law ought to tolerate moral wickedness by according citizens legal rights to do moral wrongs. I set aside cases in which tolerance is proper because the morality of the conduct in question is uncertain or sufficiently contested by equally reasonable persons so as to make liberty the appropriate default solution for the state. Instead, I confine my inquiry to cases in which lawmakers are confident that the conduct in question is blameworthy, so that doubt and disagreement cannot be said to be sufficient reasons for staying the hand of the state. As I argue in Part I, both consequentialist and deontological moral theories can be thought to permit immoralities that are not violations of consequentialist or deontological obligations. Rule-consequentialists require tolerance of act-consequential wrongs that are done in the name of their rules; and deontologists require tolerance of consequentially sub-optimal deeds that are categorically permitted. While we may have aretaic obligations to become the kinds of persons who do not abuse deontological permissions, I explore a series of reasons to think that those who subscribe to an aretaic moral theory that substitutes concerns for character for concerns for actions will nevertheless have good grounds to place the cultivation of good character beyond the scope of the state. The question is harder when we move from immoralities that do not violate obligations to immoralities that do violate such obligations. Can consequentialists make sense of the state according persons liberty to do what is consequentially prohibited? Can deontologists defend not just the liberty to misuse permissions but the liberty to violate categorical prohibitions? I argue in Part II that there may be sound arguments for why liberty is either intrinsically good or instrumentally good for the achievement of other intrinsically good things, in which case, consequentialists have sounds reasons for supposing that the state ought to tolerate wickedness, tu cour , or tolerate it when it is a price that purchases greater goods. And I argue in Part III that our best deontological theory may contain within it maxims that categorically prohibit legislators from prohibiting violations of categorical maxims on the part of citizens. For example, they may be enjoined from invading citizens' privacy in the ways required to detect citizens' wrongdoing; or they may be enjoined not to prohibit what they cannot equally enforce against all. The upshot of my analysis is that a theory of liberal tolerance does not depend upon claims of reasonable doubt and disagreement amongst lawmakers and citizens, as is so often supposed amongst liberal political theorists. Even if reasonable persons agree that a kind of conduct is immoral, and even if lawmakers are in little doubt about its immorality, there are powerful moral reasons why lawmakers might be morally obligated to tolerate its persistence. (shrink)

That Kant’s moral thought is invoked by both advocates and opponents of a right to assisted dying attests to both the allure and and the elusiveness of Kant’s moral thought. In particular, the theses that individuals have a right to a ‘death with dignity’ and that assisting someone to die contravenes her dignity appear to gesture at one of Kant’s signature moral notions, dignity. The purposes of this article are to outline Kant’s understanding of dignity and its implications for the (...) ethics of assisted dying. According to Kant, that which has dignity must be treated as an end in itself and may not permissibly be exchanged for that which merely has price. Kant’s reasoning thus seems to preclude acts of self-killing, including voluntary assisted dying, that rest on individual self-interest, since a person’s interests merely have price. However, a recognizably Kantian view of dignity can permit assisted dying under two sets of circumstances: First, it can be permissible for agents who anticipate a degradation of their rational agency due to conditions such as dementia to direct others to end their lives once sufficiently demented. In so doing, such agents in effect exercise a right to impose obligations on others regarding how their bodies, which will at some future point no longer be the vessels of their rational agency, are to be disposed of. Second, Kant errs in supposing that our dignity can stem solely from our moral personality, i.e., from our capacity to abide by universalizable moral principles. Rather, complete dignity also requires the capacity for setting discretionary ends and the means to those ends, i.e., the dignity of humanity. Individuals with prolonged and intense depression, in severe pain, or with serious disability may lack humanity while retaining their moral personality. In such cases, I propose that their opting to end their lives, with or without the assistance of others, does not amount to exchanging their dignified selves for something which merely has price and is therefore not objectionable on Kantian grounds. (shrink)

No law in any jurisdiction that permits physician assisted dying offers individuals a medically assisted death without the need to comply with certain criteria. The Netherlands is no exception. There is evidence to suggest that physicians are averse to providing an assisted death even when the Dutch ‘due care criteria’ have been met and the unbearable pain and suffering requirement is especially difficult to satisfy. Some individuals with an enduring desire to die who do not meet the ‘due care’ criteria (...) under the Dutch legislation turn to other means of achieving a self-appointed death. This paper explores two alternative methods of securing a self-determined death (an assisted death involving lay assistors or a self-hastened death by stopping eating and drinking), and raises the question of how far the law should recognise autonomy in the context of physician assisted death. (shrink)

Background Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. Methods 28 semi-structured interviews were conducted with 32 family caregivers and (...) one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. Results Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient’s illness; progression or state of a patient’s illness; patient’s geographical location; and the capability and assertiveness of a patient and/or caregiver. Conclusions Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria’s existing policy approach appears to preference institutional positions over patient’s choice given existing power dynamics. (shrink)

In _Discrimination Against the Dying_, Philip Reed argues, among other things, that ‘right to die laws (euthanasia and assisted suicide) also exhibit terminalism when they restrict eligibility to the terminally ill’. 1 Additionally, he suggests ‘the availability of the option of assisted death only for the terminally ill negatively influences the terminally ill who wish to live by causing them to doubt their choice’. 1 I argue that on scrutiny, neither of these two points hold. First, we routinely limit a (...) course of treatment to only those for whom we believe the treatment might provide a benefit. Typically, we do not think hastening death provides benefit when an individual is not experiencing a terminal illness. Thus, I conclude, either all treatments are discriminatory, or medical aid in dying is not. Second, I argue that permitting individuals to refuse or remove life sustaining care may very well cause... (shrink)

Death, like many social problems, has become medicalized. In response to this medicalization, physician-assisted suicide has emerged as one alternative among many at the end of life. And although the practice is currently legal in the states of Oregon and Washington, opponents still argue that PAS is unethical, is inconsistent with a physician's role, and cannot be effectively regulated. In comparison, Switzerland, like Oregon, permits PAS, but unlike Oregon, non-physicians and private organizations play a significant role in assisted death. Could (...) the Swiss model be the answer? The following essay explores the Swiss model of assisted suicide for its potential to enhance the regulation of PAS, reduce physician involvement, and perhaps demedicalize the way we die. (shrink)

Background Most jurisdictions that allow euthanasia and assisted suicide (AS) regulate it through the medical profession. However, the extent and nature of how medicine should be involved are debated. Swiss AS practice is unusual in that it is managed by lay AS organizations that rely on a law that permits AS when done for nonselfish reasons. Physicians are not mentioned in the law but are usually called upon to prescribe the lethal medications and perform capacity evaluations.Methods We analyzed in-depth interviews (...) of 23 Swiss AS experts including ethicists, lawyers, medical practitioners, and senior officials of AS organizations for their views on AS.Results Although there was agreement on some issues (e.g., need for better end-of-life care), the interviewees’ preferred model for AS, and the nature of preferred medical involvement, varied, which we categorized into five types: preference for AS practice as it occurred prior to lay AS organizations; preference for the current lay model; preference for a modified lay model to increase autonomy protections while limiting medical AS normalization; preference for various types of more medicalized models of AS; and, ambivalence about any specific model of medical involvement. The rationales given for each type of model reflected varying opinions on how medicine’s role would likely impact AS practice and demonstrated the experts’ attitudes toward those impacts.Conclusion The dynamics within the Swiss AS regime, as reflected in the varying views of Swiss AS experts, shed light on the dilemmas inherent to medical scope and involvement in AS, which may have implications for debates in other jurisdictions. (shrink)

The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada’s assisted dying law. The question of whether changes to a country’s assisted dying legislation lead to descents down slippery slopes has also come to the fore—as it does any time a jurisdiction (...) changes its laws. We explore these two questions through the lens of Canada’s experience both to inform Canada’s ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada’s Medical Assistance in Dying law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada’s new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada’s journey supports slippery slope arguments against permitting assisted dying. All data relevant to the study are included in the article. (shrink)

In June 2019 Victoria became the first state in Australia to permit “voluntary assisted dying”, with its governance detailed in the Voluntary Assisted Dying Act 2017. While taking lead from the regulation of medically assisted death practices in other parts of the world, Victoria’s legislation nevertheless remains distinct. The law in Victoria only makes VAD available to persons determined to be “already dying”: it is expressly limited to those medically prognosed to die “within weeks or months.” In this article, we (...) discuss the emergence of the Victorian legislation across key formative documents. We show how, in devising VAD exclusively for those “already at the end of their lives”, the Victorian state mobilizes the medico-legal category of the already dying. We argue that this category functions to negotiate a path between what are seen as the unacceptable alternatives of violent suicide on the one hand, and an unlimited right to die on the other. Further, we argue that the category of the already dying operates to make medical practitioners the gatekeepers of this new life-ending choice and effectively limits the realization of autonomy at the end of life. (shrink)

I defend a certain claim about rationing in the context of HIV/AIDS, namely, the 'priority thesis' that the state of a developing country with a high rate of HIV should provide highly active anti-retroviral treatment (HAART) to those who would die without it, even if doing so would require not treating most other life-threatening diseases. More specifically, I defend the priority thesis in a negative way, by refuting two influential and important arguments against it inspired by the Kantian principle of (...) respect for persons. The 'equality argument' more or less maintains that prioritizing treatment for HIV/AIDS would objectionably treat those who suffer from it as more important than those who do not. The 'responsibility argument' says, roughly, that to ration life-saving treatment by prioritizing those with HIV would wrongly fail to hold people responsible for their actions, since most people infected with HIV could have avoided the foreseeable harm of infection. While it appears that a Kantian must think that one of these two arguments is sound, I maintain that, in fact, respect for persons grounds neither the equality nor responsibility argument against prioritizing HAART and hence at least permits doing so. If this negative defence of the priority thesis succeeds, then conceptual space is opened up for the possibility that respect for persons requires prioritizing HAART, which argument I sketch in the conclusion as something to articulate and defend in future work. (shrink)

Photo by Hannah Busing on Unsplash INTRODUCTION Religion has long provided guidance that has led to standards reflected in some aspects of medical practices and traditions. The recent bioethical literature addresses numerous new problems posed by advancing medical technology and demonstrates an erosion of standards rooted in religion and long widely accepted as almost axiomatic. In the deep soul-searching that pervades the publications on bioethics, several disturbing and dangerous trends neglect some basic lessons of philosophy, logic, and history. The bioethics (...) discourse on medical aid in dying emphasizes similarity over previously recognized important distinguishing features. For example, it overplays a likeness between assistance in dying and the withdrawal of life-saving technology. In many bioethics’ topics, arguments based on a logical continuum are used to question the lines demarcating important moral differences. l. The Line Between Ethical and Not: Logic Based on Continuum Careful case selection, often either end of a continuum, allows the tearing down or ridiculing of many rules and codes across most professions and fields of interest. This situation holds true for traffic laws as well as medical ethics guidelines. It is relatively simple for those who desire to attack a particular viewpoint by selecting a case that makes that position seem untenable. In the ethics realm, good and bad medicine exist at opposite ends of an ethical continuum, with many practices lying in between. For example, much of medical ethics exists between the Nazi criminal physicians and the most sainted nurse or physician. A gradual progression occurred over less than two decades from a utilitarian position that supported limited euthanasia for those with certain mental illnesses to genocide. German society embraced a utilitarian ethic in which the value of human life no longer was intrinsic but instrumental.[1] Many morally significant points on a continuum were then ignored as the misguided utilitarian policy rampantly continued. A point in the continuum to distinguish between ethically justifiable and that which is not can be difficult to identify compared to the two extremes. This continuum is not unique to ethics but can be applied to almost any other aspect of human life and endeavor. Between a severely ill schizophrenic person and a superbly well-adjusted individual, there is a continuum of mental and psychological function. The existence of a continuum should not paralyze thinking and prevent us from drawing lines and identifying moral differences based on objective criteria as well as moral philosophy. Yet, by focusing on a continuum, many bioethicists use logic to disregard dividing lines between an "ethical" and an "unethical" act. Unfortunately, sometimes bioethicists draw revolutionary conclusions that would change the scope of medical practices which is accepted as ethical. There are many examples of similar shifts on the continuum. Many authors argue for the ethical permissibility of abortion by pointing out that the human fetus is no different in various characteristics, one arguing it is as like an ape or chick as it is like a person,[2] and does not achieve unique human and individual characteristics until well into the first year of life.[3] While human fetuses arguably do not have certain distinctive qualities of personhood, most people shy away from the logical next conclusion: permitting infanticide. For example, Joshua Lederberg condemns infanticide, in the face of biological illogic, because of our emotional commitment to infants, to me, a relatively weak explanation. Sir Francis Crick suggests we might consider birth at two days of life in order to decide whether an infant is a "suitable" member of society.[4] Giublini and Minerva suggest that infanticide should be permissible since late pregnancy abortions are permissible, arguing there is no significant difference between a fetus just before birth and an infant just after birth.[5] Clearly the continuum approach would allow for subjective arguments in favor of later infanticide at other points many days post-birth. Years ago, with a cynical tone, I mentioned infanticide as a further step on the continuum beyond abortion, and I was rightly shouted down as being deliberately provocative to assert the logic would ever stretch so far. While it is not an accepted mainstream position, the movement in academic settings from widespread condemnation to limited possible acceptance of infanticide has taken place in an incredibly short time. Public opinion and medical opinion in these areas have shifted dramatically in a short time. In another area, from a biological and chemical point of view, there is a continuum from man down to a single carbon atom. Yet, it would not seem logical to ignore the emotional differences, the meaning of personhood, or the moral distinction between killing an insect and killing a person. ll. A False Continuum: Medical Aid in Dying I assert that there has been an erosion of ethical guidelines in recent years attributable to using continuums to camouflage important distinctions. James Rachels’ work on active and passive euthanasia, which contends that the two are ethically identical, exemplifies that logic.[6] He illustrates this thesis, using a continuum to compare different scenarios with like consequences as morally equivalent, by comparing the deliberate drowning of a child with a deliberate failure to rescue a drowning child when easily able to do so. The author's comparison proposes that since much of the medical profession has already made peace with withholding treatment in order to hasten death, consistency inexorably demands that we permit active euthanasia as well.[7] When permission for active euthanasia was first introduced, it was limited exclusively to patients suffering severely from an intractable, incurable, and irreversible disease. These guidelines have been continuously eroded. There is now a substantial serious consideration for permitting active euthanasia of healthy elderly individuals who feel that they have completed their lives and are "tired of living."[8] There are many moral and factual differences along the ethical continuum. In human life, there is a difference between a live baby and a fetus, between a viable fetus and one that is not, between a fetus and a zygote, and between a zygote and a sperm cell. Similarly, there is a difference between pulling a trigger to kill someone and not interfering in preventing his death, which is reprehensible though both may be. There is a difference between not resuscitating an 80-year-old man with cancer when his heart stops and injecting him with a fatal dose of potassium chloride. I argue that an overt act of taking life repels civilized human beings is to be commended and encouraged as the reverence for human life or even for just a moment of human life is one of the great contributions of our civilization. CONCLUSION As an orthodox Jew, I feel that divinely inspired guidelines that have stood the test of centuries shape my beliefs, and such guidelines contradict medical aid in dying. I cannot speak to the viewpoint of those who do not access religion in defining their moral stance, nor do I implicate them in the current bioethics' trends, as I am not aware of the personal role of religion in the lives of most such authors. While many nonreligious people have a firm philosophical grounding and oppose medical aid in dying, I suggest that in the absence of any religious or other absolute standards, developing logically defensible ethical guidelines may be challenging. At the least, religion may play a role in defining the points on the continuums that are ethically meaningful and refuting the trending beliefs that if the endpoint is the same, allowing different methods of arriving at that end are somehow ethically equal. The continuum of ways death may result does not negate analysis of whether death is brought about in ways that recognize the importance of life. The German philosopher Hans Jonas said, "It is a question whether without restoring the category of the sacred, the category most thoroughly destroyed by the scientific enlightenment, we can have an ethics able to cope with the extreme powers that we possess today and constantly increase and are compelled to use."[9] While countries vary on the role of religion in policy, with many emphasizing freedoms of religion, a recent position paper released by a group of Jewish, Christian, and Moslem leaders suggested the need for agreement on the unique sanctity of human life.[10] I would recommend that such a document serve as an example of consensus on critical foundational bioethical guidelines for democratic secular societies. - [1] Alexander L Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. A geneticist looks at contraception and abortion, Annals of Internal Medicine 67, sup 2, 25-27. https:/doi.org/10.7326/0003-4819-67-3-25 [3] Ibid. [4] Editorial, Sociology: Logic of biology. Nature 220, 429 https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J Active and passive euthanasia. New England Journal of Medicine 292, 78-80 [7] Ibid. [8] Cohen-Almagor R Euthanizing people who are "tired of life". in Euthanasia and Assisted Suicide-Lessons from Belgium. Ch 11 of Euthanasia and Assisted Suicide, Cambridge University Press pp173-187. 2017 and DOI; https://doi.org/10.1017/9781108182799.012 [9] Hans Jonas, Technology and Responsibility: Reflections on the New Tasks of Ethics, 1972, found as Chapter IX, Philosophical Essays, 1980. https://inters.org/jonas-technology-responsability [10] A position paper of the Abrahamic Monotheistic religions on matters concerning the end-of-life. Vatican Press 28 October 2019 https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2019/10/28/191028f.html. (shrink)

Because complex organs taken from unequivocally dead people are not suitable for transplantation, human death has been redefined so that it can be certified at some earlier stage in the dying process and thereby make viable organs available without legal problems. Redefinitions based on concepts of "brain death" have underpinned transplant practice for many years although those concepts have never found universal philosophical acceptance. Neither is there consensus about the clinical tests which have been held sufficient to diagnose the irreversible (...) cessation of all brain function – or as much of it as is deemed relevant – while the body remains alive. For these reasons, the certification of death for transplant purposes on "brain death" grounds is increasingly questioned and there has been pressure to return to its diagnosis on the basis of cardiac arrest and the consequent cessation of blood circulation throughout the body. While superficially a welcome return to the traditional and universally accepted understanding of human death, examination of the protocols using such criteria for the diagnosis of death prior to organ removal reveals a materially different scenario in which the circulatory arrest is not certainly final and purely nominal periods of arrest are required before surgery begins. Recognizing the probably unresolvable conflict between allowing enough time to pass after truly final circulatory arrest for a safe diagnosis of death and its minimization for the sake of the wanted organs, Verheijde and colleagues follow others in calling for the abandonment of the "dead donor rule" and the enactment of legislation to permit the removal of organs from the dying, without pretence that they are dead before that surgery. While it may be doubted whether such a "paradigm change" in the ethics of organ procurement would be accepted by society, their call for its consideration as a fully and fairly informed basis for organ donation is to be applauded. (shrink)

Der Beitrag analysiert den Aphorismus 377 des 5. Buch der Fröblichen Wissenschaft, die eine ausführliche Charakterisierung der Idee eines gutes Europäers enthält. Durch die Betrachtung der komplexen Entstehung des Aphorismus werden die vielschichtigen Bedeutungen dieser Auffassung beleuchtet. Die Evokationskraft, die den gesamten Aphorismus prägt, wird als Symptom eines offenen Systems unde einer dynamischen Ganzheit, in denen die Auffassung des guten Europäers ihre Konturen annimmt, besonders betont. Innerhalb dieser Offenheit stellt sich der gute Europäers ihre Kunturen annimmt, besonders betont. Innerhalb dieser (...) Offenheit stellt sich der gute Europäer als Produkt einer Übergangszeit dar, die mit Situationen jenseits der traditionellen Wertbestimmung experimentieren will. So schwantk der gut Europäer zwischen Modernität und Unzeitgemäßheit; eine solche paradoxe Schwankung erlaubt, auch die möglichen "politischen" Konnotationen der Idee eines guten Europäers besser zu verstehen.This study analyses aphorism 377 of the fifth book of the Gay Science, which contains an exhaustive characterization of the idea of the good European. Consideration of the complex genesis of the aphorism brings to light the many meanings of this concept. The evocative force that characterizes the entire aphorism is particularly highlighted as a indication of the openness of the system and its dynamic totality. Within this openness, the good European is a product of an era of transition that creates situations beyond traditional determinations of value. In this way, the good European oscillates between modernity and timelessnes. This paradoxical oscillation permits a better understanding also of possible "political" connotations of the idea of the good European. (shrink)

Although he was born in Gaza, Palestine, Elias Rashmawi was issued a permanent deportation order by the Israeli High Court because of his involvement in Palestinian organizing while a student in the United States. In November 2000, as the Second Intifada raged on, Rashmawi’s father passed away, and he was granted a limited permit to his homeland to attend the funeral. “How many fathers must die before we are all allowed to return,” he asks in this essay that reifies the (...) brevity and pain of his truncated visit. (shrink)

In this paper, we propose and defend three economic arguments for permitting assisted dying. These arguments are not intended to provide a rationale for legalising assisted suicide or euthanasia in...

In this chapter I consider the narrow and wider benefits of permitting assisted dying in the specific context of organ donation and transplantation. In addition to the commonly used arguments, there are two other neglected reasons for permitting assisted suicide and/or euthanasia: assisted dying enables those who do not wish to remain alive to prolong the lives of those who do, and also allows many more people to fulfill their wish to donate organs after death. In the first (...) part of this chapter I explore the possibility of allowing those who die with assistance to donate their organs and the potential benefits of doing so in countries where some form of assisted dying is legal; in the second part I consider the added force that organ donation considerations bring to the argument in favour of legalizing assisted dying in countries where such practices remain forbidden. (shrink)

When medical assistance in dying (MAiD) was legalized in Canada in June 2016, the question of allowing decisionally capable persons to make advance requests in anticipation of later incapacity was reserved for further consideration during the mandatory parliamentary review originally scheduled to begin in June 2020 (but since delayed by COVID-19). In its current form the legislation does not permit such requests, since it stipulates that at the time at which the procedure is to be administered the patient must give (...) “express consent” to receiving it. Since express consent presupposes decisional capacity, this requirement rules out administering MAiD to a patient who has lost capacity. Amendments to the legislation passed by Parliament in March 2021 open the door slightly by allowing advance requests by patients after they have been approved for MAiD, if they fear losing capacity before the procedure can be administered. But this provision would apply only to patients whose natural death was deemed to be “reasonably foreseeable”, and would continue to exclude (a) requests made after diagnosis of a “grievous and irremediable medical condition” but in advance of approval for MAiD, and (b) requests made before such a diagnosis. My aim in this paper is twofold: to explore the ethical and legal issues concerning advance requests for MAiD, and to argue for expanding provision for such requests to include both of these further scenarios. (shrink)

In their book Debating Euthanasia, Emily Jackson and John Keown present respectively arguments in favour of and against the legalization of (some instances of) euthanasia and assisted suicide. Jackson advances a case based on a principled commitment to a secular, liberal legal system, arguing that obligations rooted in compassion require the careful development of laws to permit assisted dying. Keown defends the status quo, arguing that the law ought to sustain a prohibition against assisted dying, both out of a principled (...) commitment to the inviolability of life doctrine, and because satisfactory regulation will be impossible to draft. I question the strength of each author’s essay. Jackson, I argue, does not take sufficiently seriously the plausibility of secular moral objections to assisted dying. Keown, meanwhile, overstates the inviolability principle’s place in English law. Focusing particularly on Keown’s essay, I go on to consider the approach taken to ‘debating euthanasia’, and suggest that it betrays more about the direction of the public debate, and the fragility of ‘the case against’, than he would perhaps wish. (shrink)

Within the phenomenological perspective the reductive method, as proceeding through the path (μετα-οδός), allows the subject to refer to its own living structure. It is crucial to bring out the aware character of this relationship, because such consciousness is achieved by an unaware subjectivity. Since the subject arises ab initio in a hyletic-temporal field, it has to carry out its methodological procedure according to definite modes, that is the time-consciousness’ modes. The method of reduction, which aims to uncover what is (...) not thematic, constitutes the radical action, which permits the subject to represent the way of being of its inner structure. In this sense, the reduction is the highest act of representation (Vergegenwärtigung), because its procedure takes place by a thematizing return of the subject to itself. To carry out the reductive method, i.e. to perform a self-unveiling, the subject has to follow the patterns of a pre-existent life, which are already temporal and to which it always is related. Though the reduction is a free choice of a subject, it has to conform to a prescribed procedure. (shrink)

However, the barriers and facilitators of such changes - law reform perspectives - have been virtually ignored. Why do so many attempts to change the law fail but others are successful? International Perspectives on End-of-Life Law Reform aims to address this question by drawing on ten case studies of end-of-life law reform from the United Kingdom, the United States, Canada, the Netherlands, Belgium and Australia. Written by leading end-of-life scholars, the book's chapters blend perspectives from law, medicine, bioethics and sociology (...) to examine sustained reform efforts to permit assisted dying and change the law about withholding and withdrawing life-sustaining treatment. Findings from this book not only shed light on changing end-of-life law but also provide insight more generally into how and why law reform succeeds in complex and controversial social policy areas. (shrink)

Assisted dying is a divisive and controversial topic and it is therefore desirable that a broad range of interests inform any proposed policy changes. The purpose of this study is to collect and synthesize the views of an important stakeholder group—namely people with disabilities —as expressed by disability rights organisations in Great Britain. Parliamentary consultations were reviewed, together with an examination of the contemporary positions of a wide range of DROs. Our analysis revealed that the vast majority do not have (...) a clear public stance; those that do exhibit a significant diversity of opinion. DROs opposing legislation on assisted dying have argued that it would be premature, misguided, inequitable and culturally undesirable. Some specify conditions that would have to be satisfied before they could support legalisation, such as radical improvements in health and social care services and the elimination of discrimination against PwD. DROs supporting assisted dying maintain that a change in the law would promote autonomy, end intense suffering, can be delivered safely and is supported by the DRO’s membership. The discussion considers the reasons why several DROs adopt a neutral stance and the argument is made that, whatever their overarching stance on the issue, DROs need to be involved in the policy debate so that the crucial perspectives of PwD are heard and addressed. This is an important message for countries around the world that permit, or are considering legalising, assisted dying. (shrink)

Most of the processes subsumed under »digitalization« have in common that they permit switching and simultaneity of sender and recipient roles over a broad range of communications. Preeminently, such communications provide and process information. However, the progress of digitalization in modern lifeworlds is not primarily driven by the development of digital technology. Digital technology is but the appropriate medium for enabling the exchange of the respective formats of information. Its thrust is embedded in a cumulative history of translation of analogue (...) world-relations into such formats of information and, moreover, the progressive transformation of reality in data-structures that can be digitally mapped and controlled. Such structures are attractive because they render our access to and handling of reality more secure and more predictable. Yet they also engender increasing helplessness and discontentment at the boundaries of the digitally controllable world. (shrink)

Helga Kuhse suggested in 1985 at a session of the World Federation of Right to Die Societies in Nice, that once dehydration to death became legal and routine in hospitals, people would, on seeing the horror of it, seek the lethal injection. The strategy of legalising passive euthanasia is itself flawed. Laing argues that the Mental Capacity Bill threatens the vulnerable by inviting breaches of arts 2,3,5,8, and 14 of the European Convention on Human Rights. Most at risk are the (...) disabled and incapacitated. Sections permitting non-therapeutic research and non consensual sterilisation are at odds with the Nuremberg Code. New third party powers to dehydrate the vulnerable permit new systemic human rights abuse of a clinical though not historically unfamiliar variety. (shrink)

Le livre de Borkenau, „Der Übergang vom feudalen zum bürgerlichen Weltbild“ développe une nouvelle théorie de la naissance de la pensée moderne. Il s’attache à rechercher l’origine, moins de telles ou telles idées particulières que des concepts fondamentaux et des méthodes de penser de l'époque moderne. Borkenau considère avant tout la représentation mécaniste du monde telle qu'elle a été fondée dans la philosophie de Descartes et de ses successeurs comme décisive pour la pensée moderne et il élucide ses conditions sociologiques.L'étude (...) de Grossmann part du livre de Borkenau qu'il soumet à la critique et il essaye d'indiquer de manière indépendante une meilleure voie qui mène à la compréhension de la formation de la pensée bourgeoise. Ses arguments se rapportent avant tout à deux groupes de problèmes. D'après Borkenau, c'est au début du xvne siècle que la conception mécaniste du monde l'a emporté sur la philosophie qualitative qui régnait auparavant. Cette interprétation est jugée par Grossmann comme une méconnaissance de l'histoire réelle des idées et des faits. L'origine des questions fondamentales de la mécanique doit être cherchée à la Renaissance et Léonard de Vinci est un de ses créateurs. Ces théories nouvelles, dégagées en grande partie de l'étude des machines de son temps, se sont développées par différentes voies jusqu'à Galilée et Descartes, dont les doctrines ne marquent donc pas le début de la pensée mécaniste.L'autre critique fondamentale est étroitement liée à celle-ci. Elle concerne l'explication que donne Borkenau de la représentation mécaniste. Si celle- ci a pris naissance au xvne siècle, la condition essentielle de cette réalisation doit donc s’être produite à peu près à cette époque. D'après Borkenau cette condition serait la diffusion des manufactures. Avec la division de l'activité artisane en activités uniformes non qualifiées à l'intérieur de la manufacture, serait né le concept d'un travail social abstrait. La décomposition du processus de travail en mouvements simples dans la manufacture aurait rendu comparables les heures de travail. Le calcul avec du travail abstrait constituerait la base de la représentation mécaniste du monde. Grossmann montre en s'appuyant sur Marx que le plus souvent il ne saurait être question de division de travail dans les manufactures, mais que, en règle générale, des artisans qualifiés travaillaient réunis dans un même local. Ce n’est pas le calcul avec les heures de travail, mais l'évolution du machinisme qui aurait été la cause immédiate de la mécanique scientifique. Cette genèse remonte sans doute à la Renaissance et a très peu à faire avec les manufactures qui ont été finalement refoulées par l'industrie des machines.Alors que Borkenau, lorsqu'il vient à parler du conditionnement social des philosophes et des savants, remonte surtout aux batailles des partis politiques, Grossmann ne voit dans les partis qu’un facteur de l'ensemble de la situation complexe, à partir de laquelle s'explique le mouvement des idées modernes. Une théorie suffisante de l'évolution de la pensée moderne implique qu'on tienne compte de la totalité des forces sociales.Franz Borkenau's book „The Transition from Feudal to Modern Thought“ („Der Übergang vom feudalen zum bürgerlichen Weltbild“), serves as background for Grossmann's study. The objective of this book was to trace the sociological origins of the mechanistic categories of modern thought as developed in the philosophy of Descartes and his successors. In the beginning of the 17th century, according to Borkenau, mechanistic thinking triumphed over mediaeval philosophy which emphasized qualitative, not quantitative considerations. This transition from mediaeval and feudal methods of thought to modern principles is the general theme of Borkenau's book, and is traced to the social changes of this time. According to this work, the essential economic change that marked the transition from mediaeval to modern times was the destruction of the handicraft system and the organization of labor under one roof and under one management. The roots of the change in thought are to be sought here. With the dismemberment of the handicraft system and the division of labor into relatively unskilled, uniform, and therefore comparable activities, the conception of abstract homogeneous social labor arises. The division of the labor process into simple, repeated movements permits a comparison of hours of labor. Calculation with such abstract social unities, according to Borkenau, was the source from which modern mechanistic thinking in general derived its origin.Grossmann, although he considers Borkenau’s work a valuable and important contribution, does not believe that the author has achieved his purpose. First of all, he contends that the period that Borkenau describes as the period of the triumph of modern thought over mediaeval should not be placed at the beginning of the 17th century, but in the Renaissance, and that not Descartes and Hobbes but Leonardo da Vinci was the initiator of modern thought. Leonardo's theories, evolved from a study of machines, were the source of the mechanistic categories that culminated in modern thought.If Borkenau’s conception as to the historical origin of these categories is incorrect in regard to time, Grossman claims it follows that it is incorrect also in regard to the social sources to which it is ascribed. In the beginning, the factory system did not involve a division of labor into comparable homogeneous processes, but in general only united skilled handicraftsmen under one roof. The development of machinery, not the calculation with abstract hours of labor, is the immediate source of modern scientific mechanics. This goes back to the Renaissance and has relatively little to do with the original factory system that was finally superseded by the Industrial Revolution.While Borkenau, in tracing the social background of the thought of the period, relies chiefly on the conflicts and strife of political parties, Grossmann regards this as one element only in the formation of the general social situation, which in its entirety and in the interaction of its elements explains the development of modern thought. (shrink)

Background Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with (...) persons with lived experience of mental illness.Methods We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.Results A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.Conclusions Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk. (shrink)

In 20141 and 2016,2 respectively, Québec and Canada adopted legislation permitting medical assistance in dying (MAID). In this context, the question of whether persons with mental disorders should be able to access MAID has received considerable scrutiny.Over the last 5 years, I have been involved in the academic and policy debates about assisted dying for persons with mental disorders. Policymakers and clinicians alike demand that public policy be based on 'evidence' by which they tend to mean empirical, usually quantitative, (...) data. There is little acknowledgement that some questions are not empirical and that facts require interpretation.The debate about whether a request for assistance in dying by a person with a... Read More. (shrink)

This book, written both for a Canadian and an international readership, provides a multidisciplinary review of the framework and performance of the Canadian Medical Assistance in Dying (MAID) program. In the first five years (2015-2021) of operation, this program delivered voluntary euthanasia and assistance in suicide to over 30,000 Canadian residents, presently representing a 30% annual growth. Looking back on these first five years, the 30 Canadian scholars and clinicians contributing to this volume raise important issues and attempt to answer (...) key questions that have arisen in regards to its operation and its stated objectives. This volume strikes the most appropriate balance between the autonomy of persons who seek medical assistance, versus the interests and protection of vulnerable persons. Finally, the book makes suggestions on how the program can presently be improved. It identifies gaps in knowledge about MAID’s operational program and its impact on individuals, families and society in order to stimulate the necessary research that is essential to the evolution of a healthy and well-balanced program. As a first, comprehensive examination of medically assisted deaths in Canada, this publication will be of great value to lay, professional, academic, political audiences both domestically and internationally, especially in jurisdictions that are examining their options of permitting assisted deaths. (shrink)

In a recent article, Henri Wijsbek discusses the 1991 Chabot “psychiatric euthanasia” case in the Netherlands, and argues that Chabot was justified in helping his patient to die. Dutch legislation at the time permitted physician assisted suicide when the patient’s condition is severe, hopeless, and unbearable. The Dutch Supreme Court agreed with Chabot that the patient met these criteria because of her justified depression, even though she was somatically healthy. Wijsbek argues that in this case, the patient’s integrity had been (...) undermined by recent events, and that this is the basis for taking her request seriously; it was unreasonable to expect that she could start again. In this paper, I do not challenge the Dutch euthanasia criteria in the case of somatic illness, but I argue that both Chabot and Wijsbek are wrong because we can never be sufficiently confident in cases of severe exogenous depression to assist the patient in her irreversible act. This is partly because of the essential difference between somatic and mental illness, and because of the possibility of therapy and other help. In addition, I argue that Wijsbek’s concept of integrity cannot do the work that he expects of it. Finally, I consider a 2011 position paper from the Royal Dutch Medical Association on euthanasia, and the implications it might have for Chabot-style cases in the future. (shrink)

The basic thought of Schweitzer's ethic, the reverence for life, has manifold significance. First, it is an appeal to our moral feeling. But secondly, Schweitzer lent this thought also a general, fundamental and therewith philosophical meaning: proceeding from the “most immediate and encompassing fact of consciousness,” described by him with the proposition “I am life that will live in the midst of life that will live,” Schweitzer believed to have found in the idea of reverence for life the fundamental principle (...) of all morality; this consists in the fact “that I experience the need to extend to all wills to live the same reverence that I extend to my own.” In addition to its effect on moral feeling and on ethical theory, the future of the thought, “reverence for life,” also depends on its compliance in the activity of men.The future prospects of the appeal to moral feeling appear good insofar as testimonies from history permit one to assume that the awareness of the reverence for life can be awakened in all men. The ancient Greeks knew such sensibility in theaidos, Goethe in the “reverence for that which is in our midst.” This ever strengthening recognition among the peoples of the earth will, through historically succeeding generations, increasingly eliminate a full disregard for such reverence.Less promising are the prospects of acknowledging the reverence for life as a fundamental principle of morality. On its basis Schweitzer rests his aversion to harming anything living. He does not fail to see thereby that, in order to preserve life, we must destroy some life (at least that of plants). But, says Schweitzer, I become guilty in sacrificing life, and we must constantly remain conscious of this guilt; any attempts at justification, through considerations of differences in the value of various lives, must be rejected.However, an ambiguity in the word “guilt” underlies Schweitzer's position. On the one hand “guilt” is understood as a regrettable cause for the subsistence or eventuation of an evil, on the other as the moral reprehensibility of an attitude. Only the latter represents guilt in a moral sense. Whoever follows the necessity to destroy other, less valuable life in order to preserve his own or another life, assumes guilt only in the second sense. Therefore ethics must raise and pursue the question concerning the value priority of one life over another. This question leads to an encounter with the modern directions of ethics which proceed from the concept of value, and to the continuation of Schweitzer's ethics through this encounter. Schweitzer's explanation that life in the world is “to be brought to its highest value” likewise conduces to the same point, since it necessitates an investigation of the rank order of values.We can note a slow progress of the reverence for life in the private domain of human activity. On the other hand in the interrelationship of peoples there is danger of monstrous mass murder through the atomic bomb. (shrink)

Those supporting laws permitting assisted suicide seem to enact a thin morality, one that permits people who desire AS to get it in the terminal stages of an illness, and that provide safeguards both for those who desire AS and do not desire it. This article explores the way in which all AS legislation subtly frames the question of AS such that AS becomes the clearest option; ensconcing AS in law also gives a moral legitimacy to suicide. Thus, the (...) morality of laws permitting AS are not morally thin. I describe how AS laws create a different social imaginary for dying in Western cultures, one that competes with the traditional Christian understanding. Legalized AS is inevitable in Western liberal democracies, and I claim that the Church, which transformed the ancient Greco-Roman culture, will once again have to create alternative structures, creating a new Ars moriendi, in order to challenge the modern statecraft for killing. (shrink)

Do adherents of different religious traditions communicate and, if so, how? What enables them to do so? What is interreligious “communication”? These issues are ad dressed with reference to Wilfred Cantwell Smith's hermeneutical rule, and to inter alia Paul Knitter, Martin Heidegger, Hans-Georg Gadamer, David Tracy, and John Dunne. Four responses to the question as to what permits interreligious communication are criticised. According to a fifth response, on which the author elaborates, interreligious communication is not – as the objectivist claims (...) – possible because members of different religious traditions speak the very same language, or – as the relativist claims – impossible because they speak radically different languages. Adherents of different religions communicate, if at all, by means of an analogical language. This language is the product of persistent efforts to understand the religion/faith of the other as he or she understands it. Paradoxically, the language that permits inter religious communication is thus the product of such communication. Without thereby reverting to objectivism or an essentialist view of religion, the author identifies five “less unstable” similarities between religions. These and other “less un stable” similarities might assist believers in their efforts to under stand the religious other. (shrink)

Canada and California each introduced legislation to permit medical assistance in dying in June, 2016. Each jurisdiction publishes annual reports on the number of deaths that occurred under their respective legislations in the previous years. The numbers are disturbingly different. In 2021, 486 individuals died under California’s End of Life Option. In the same year 10,064 Canadians died under that country’s Medical Assistance in Dying (MAiD) legislation. California has a slightly larger population than Canada, and while medically assisted deaths as (...) a percentage of total deaths remained virtually unchanged in California from 2020-2021, Canada saw a 30% increase from 2020 to 2021. This essay examines some of the factors propelling Canada down the slippery slope of medically assisted suicide, as well as those that may be keeping California and other US jurisdictions from taking the slide. At a time of increasing pressure in many jurisdictions (both nationally and internationally) to liberalize access to medical assistance in dying, some lessons from this comparative analysis are offered. (shrink)

Victoria’s Voluntary Assisted Dying Act 2017 (Vic) became the first state law to permit VAD in Australia under limited circumstances from June 2019. Before this, many palliative care physicians relied on the doctrine of double effect (DDE) to justify the use of pain relievers for terminally ill patients that were known to hasten death. The DDE claims that there is a morally significant difference between intending evil and merely foreseeing some bad side-effect will occur as a result of one’s actions. (...) This article argues that the legacy of the DDE is promoting inequitable access to VAD in Victoria due to the assumption that death represents an “evil” for the patient and that the intentions of physicians providing VAD cannot be trusted. The latter claim relies on two common objections to the DDE: the risk of “purifying the intentions” and the issue of “closeness” when evaluating moral acts under this theory. (shrink)