BackgroundLiterature shows that middle-aged and older adults sometimes experience a wish to die. Reasons for these wishes may be complex and involve multiple factors. One important question is to what extent people with a wish to die have medically classifiable conditions. Aim(1) Estimate the prevalence of a current wish to die among middle-aged and older adults in The Netherlands; (2) explore which factors within domains of vulnerability (physical, cognitive, social and psychological) are associated with a current (...) class='Hi'>wish to die; (3) assess how many middle-aged and older adults with a current wish to die do not have a medically classifiable condition and/or an accumulation of age-related health problems.MethodsData of 2015/16 from the Longitudinal Aging Study Amsterdam were used for this cross-sectional study (1563 Dutch middle-aged and older adults aged between 57 and 99 years), obtained through structured medical interviews and self-reported questionnaires. Three experienced physicians assessed whether the participants with a current wish to die could be classified as having a medically classifiable condition and/or an accumulation of age-related health problems.ResultsN = 62 participants (4.0%) had a current wish to die. Having a current wish to die was associated with multiple characteristics across four domains of vulnerability, among which: self-perceived health, problems with memory, self-perceived quality of life and meaningfulness of life. Fifty-four participants with a current wish to die were assessed with having a medically classifiable condition, of which one was also assessed with having an accumulation of age-related health problems. Six people were assessed to have neither, and for two people it was unclear.ConclusionA small minority of middle-aged and older adults in the Netherlands have a current wish to die. Most of them can be classified with a medical condition and one person with an accumulation of age-related health problems. Furthermore, the findings show that having a current wish to die is multi-faceted. There is still a need for more knowledge, such as insight in to what extent suffering stemming from the medical classifiable disease contributes to the development of the wish to die. (shrink)

Wish to die statements are becoming a frequent phenomenon in terminally ill patients. Those confronted by these statments need to understand the complexity of such wishes, so they can respond competently and compassionately to the requests. If misunderstood, the statements can be taken at face-value and the practitioner may not recognise that a patient is in fact experiencing ambivalent feelings at the end of life, or they may misinterpret the expressed wish to die as a sign of clinical (...) depression. Public debate about the morality and ethics of various end-of-life care options has exploded in recent years. However, it has never been sensitive to the finer aspects of clinical reality or the experiences of patients. The Patient's Wish to Die: Research, Ethics, and Palliative Care brings together that reality and the patient's voice, combining them with different research approaches. It presents the best available knowledge and research methodologies about patients' wishes at the end-of-life, together with a series of ethical views and a discussion about the clinical implications for palliative care. The book presents material in an open and unbiased manner whilst remaining sensitive to the spiritual and existential dimensions of dying, and to the different cultural views that provide meaning to the individual. Written by the best specialists and ethics scholars from around the world, including palliative care practitioners and end-of-life scholars from countries where assisted dying practices are legalized and from those where it isn't, The The Patient's Wish to Die: Research, Ethics, and Palliative Care will prove essential reading for all those working or studying in the field of palliative care. (shrink)

Although suicide has traditionally carried a negative sanction in Western societies, this is now being challenged, and while there remains substantial public concern surrounding youth and elder suicide, there is a paradoxical push to relax the prohibition under certain circumstances. Central to the arguments behind this are the principles of respect for autonomy and the importance of rationality. It is argued here that the concepts of rationality and autonomy, while valuable, are not strong enough to substantiate a categorical "right to (...) suicide" and that the concepts of "understandability" and "respect" are more useful and able to provide the foundation for responding to a person expressing a wish to die. Roman suicide, sometimes held as an example of "rational suicide", illustrates the effects of culture, tradition and values on the attitudes to, and the practice of, suicide. (shrink)

All articles in May 2019’s special issue of Bioethics offer profound insights into the issue of “being a burden to others” in relation to wishes to die, which are highly relevant for ethical debates about end‐of‐life care and physician‐assisted dying. In this reply, we wish to stress the importance of acknowledging and analyzing the sociopolitical context of the phenomenon “being a burden” in relation to wishes to die and we will show how this analysis could benefit from a care (...) ethical approach. As discussions in care ethics have made clear, caring practices are both social and political practices. An empirical and ethical analysis of “being a burden” therefore needs to take institutional and societal norms and structures into account, in addition to first‐person experiences and concepts such as caring needs, relational autonomy, and interdependency. Besides the relevance of the sociopolitical context for the phenomenon “being a burden” as such, the sociopolitical context also seems relevant for the investigation of the phenomenon, which we will illustrate by reflecting on “being a burden” in relation to the practice of physician‐assisted dying in the Netherlands. (shrink)

The article explores the underlying reasons for patients’ self‐perception of being a burden (SPB) in family settings, including its impact on relationships when wishes to die (WTD) are expressed. In a prospective, interview‐based study of WTD in patients with advanced cancer and non‐cancer disease (organ failure, degenerative neurological disease, and frailty) SPB was an important emerging theme. In a sub‐analysis we examined (a) the facets of SPB, (b) correlations between SPB and WTD, and (c) SPB as a relational phenomenon. We (...) analyzed 248 interviews with 62 patients, their family caregivers, and professionals using grounded theory and interpretive phenomenological analysis. SPB appeared as important empathic concern in care situations. Patients expressed many sorts of concerns for others, but also perceived an altered self‐understanding that did not meet mutual expectations within relationships. In SPB associated with WTD three constellations were found: (a) WTD to unburden others; (b) patients decided against hastening death to prevent being a further burden to others (in these cases, the SPB counteracted the wish to die); and (c) both wishes for and against dying were sustained by SPB. These patients often felt paralyzed and suffered deeply. Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. We concluded that the impact of SPB on a WTD and the various meanings the facets of SPB have in balancing relationships need to be worked out individually. An early palliative and narrative approach is warranted. (shrink)

Patients at the end of their life who express a wish to die sometimes explain their wish as the desire not to be a burden to others. This feeling needs to be investigated as an emotion with an intrinsically dialogical structure. Using a phenomenological approach, two key meanings of the feeling of being a burden to others as a reason for a wish to die are identified. First, it is an existential suffering insofar as it contains the (...) perception of a plight so desperate that it can only be relieved by the end of the patient’s existence. Second, it is an empathic concern that implies caring about those who bear the burden of caring for the person at the end of their life. It is therefore a moral emotion, encompassing a series of difficulties, including the subjective perception of a stark imbalance between giving and taking, the adequacy of the representation of the caregiver burden in the patient’s mind, and the danger of diminishing the worth of one’s life out of shame or self‐denigration. R. D. Laing’s terminology of crossed perspectives in interexperience is used to systematically distinguish the actual caregiver burden, the patient’s view of the caregiver burden, the stress for the patient in feeling that s/he is a burden to the caregiver, and the caregiver’s view of the patient’s stress. The sense of being a burden implies the belief that the caregiver feels burdened, and the fear that this burden could become unbearable. (shrink)

sirIn a scholarly and thought-provoking paper, Clarke sets out to debunk the concept of “rational suicide” as nonsensical.1 His motivation in this is to undermine any support that the notion of rational suicide might give to a “categorical right to suicide”. If his enterprise were successful, however, it would go far beyond the “rights issue” and would have a profound impact on all arguments raised in support of euthanasia or physician-assisted suicide.Clarke's major thrust might be termed the argument from posthumous (...) ignorance. He begins with a claim that the process of making a rational decision involves the process of “gaining all possible facts and `imagining' all possible consequences”. He goes on to say that making a rational decision “in the consideration of life or death . . . would seem to be impossible”. It is “impossible” …. (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)

sirIn a scholarly and thought-provoking paper, Clarke sets out to debunk the concept of “rational suicide” as nonsensical.1 His motivation in this is to undermine any support that the notion of rational suicide might give to a “categorical right to suicide”. If his enterprise were successful, however, it would go far beyond the “rights issue” and would have a profound impact on all arguments raised in support of euthanasia or physician-assisted suicide.Clarke's major thrust might be termed the argument from posthumous (...) ignorance. He begins with a claim that the process of making a rational decision involves the process of “gaining all possible facts and `imagining' all possible consequences”. He goes on to say that making a rational decision “in the consideration of life or death . . . would seem to be impossible”. It is “impossible” …. (shrink)

Background This paper addresses sedation at the end of life. The use of sedation is often seen as a last resort for patients whose death is imminent and whose symptoms cannot be treated in any other way. This paper asks how to assess constellations, where patients want to hasten their death by refusing (further) life-sustaining treatment, or by voluntarily stopping eating and drinking (VSED), and wish this to be accompanied by sedation. Argument We argue that sedation is ethically and (...) legally permissible not only as a last resort, but in principle. Furthermore, we see a clear obligation to sedate in cases of acute suffering of any kind, while in some other constellations individual physicians’ objections to supposedly premature or unnecessary sedation must be respected. Such possible reservations should, however, be reconsidered in light of the fundamental ethical and legal right to a self-determined death. Conclusion In general, sedation practices should be less restrictive, and existing guidelines should be revised accordingly. (shrink)

Volume 19, Issue 12, December 2019, Page 44-45.

In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his father's condition and killed him in order to show his love.

An adolescent’s last moment of life is an emotionally and medically complex time. Children may grapple with understanding the things happening to them and with grief of a future lost; caregivers struggle to simultaneously balance deep sorrow, hope, and love; and healthcare providers fight to maintain sound medical and ethical decision making. Increased discussion regarding adolescent end-of-life care is needed so that clinicians may better understand how to engage in ethically based medical management during these events. This holds particularly true (...) in situations where potentially conflicting ideas exist between clinicians and family members. We describe the case of an acutely and terminally ill adolescent who remained cognitively intact but with rapidly advancing multiple organ failure and whose parents requested that he remain uninformed of his critical illness and prognosis. (shrink)

In this short paper I will discuss the ambiguous and, even, controversial term ‘right to die’ in the context of the euthanasia debate and, in particular, in the case of passive euthanasia. First I will present the major objections towards the moral legitimacy of a right to die, most of which I also endorse myself; then I will investigate whether the right to die could acquire adequate moral justification in the case of passive euthanasia. In the light of the Kantian (...) tradition I will argue that since rights are understood as based upon duties, the right to die should also presuppose a corresponding duty, which to me could be either an imperfect, solidarity-related duty, or an autonomy-related one, at least as far as the unwanted prolongation of life is concerned. I will conclude with the view that the right to die could actually be considered a legitimate one in the case of passive euthanasia, when the application of life-supporting techniques is against the wishes and the best interests of the patient. (shrink)

BackgroundFollowing the increased presence of the Right-to-Die Movement, improved end-of-life options, and the political and legal status of aid-in-dying around the globe, suicide tourism has become a promising alternative for individuals who wish to end their lives. Yet, little is known about this from the perspective of those who engage in the phenomenon.MethodsThis study applied the qualitative research approach, following the grounded theory tradition. It includes 11 in-depth semi-structured interviews with Israeli members of the Swiss non-profit Dignitas who contemplated (...) traveling to Switzerland for aid-in-dying.ResultsSeven themes emerged from the data analysis, including health and functioning; feelings regarding survivorship and existence; interacting with the health sector; attitudes regarding death and dying; suicide; choosing death; and choosing suicide tourism. A significant portion of the participants had experienced suicidal thoughts and had even previously attempted suicide, some more than once. Most of them referred to chronic illnesses, functional disability, and social isolation. They understand suffering within the subjective dimension, namely only by the person who is actually subjected to the disease, ailments, and disability. Participants regarded aid-in-dying in Switzerland as positive thanks to its guaranteed outcome: "beautiful death", compared to "disadvantaged dying" which places a burden on the participants' loved ones throughout the prolonged dying. Most of them do not necessarily want to have their loved ones beside them when they die, and they see no significant meaning in dying in a foreign country to which they have no emotional or civil attachment.ConclusionThe desirable approval or tragic refusal by Dignitas to participants' requests for suicide tourism enhances the paradox between the perception of aid-in-dying as a mechanism for fulfilling controlled death and its bureaucratic and materialistic characteristics specifically reflected in a paid, formalized approach to aid-in-dying that cultivate dependency and collaboration. (shrink)

Herbert, Dilinie How should health professionals respond if a patient nearing the end of life expresses a wish to hasten their death? To answer this question, this article draws upon peer‐reviewed literature, the practices of palliative care, and the experiences of two palliative care physicians, Associate Professor Natasha Michael and Associate Professor Mark Boughey. The expression of a wish to hasten death does not necessarily imply a genuine desire to hasten death or to be helped to die. To (...) the contrary, almost always this means that the patient has been overwhelmed by one or more serious concerns. While inadequate pain relief may be one such factor, more typically these concerns are social and spiritual, such as loneliness, social isolation, feeling oneself to be a burden on others, hopelessness, and fears about the process of dying. If a patient expresses a wish to hasten death, health professionals should therefore discuss with them the reasons for this request, and then devise and effectively communicate an individualised care plan which begins to address these concerns. (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.

Volume 19, Issue 10, October 2019, Page 1-2.

Background The expressions of a “wish to hasten death” or “wish to die” raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the “wish to hasten death/die” based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to (...) understand if and how the meanings behind the “wish to hasten death/die” relate to and are interpreted in light of ethical principles in palliative care. Methods We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare’s framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330. Results Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the “wish to hasten death” and/or “wish to die” were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the “wish to hasten death”. Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles. Conclusions This meta-ethnographic review shows a reduced number of qualitative studies on the “wish to hasten death” and/or “wish to die” explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed. (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)

It is not uncommon for patients with advanced disease to express a wish to hasten death. Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient’s personal and sociocultural background, or which necessarily imply taking concrete steps to ending one’s life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we (...) analyse in greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: assumptions related to patients’ moral understandings in terms of dignity, autonomy and authenticity; assumptions related to social interactions; assumptions related to the value of life; and assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients’ experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost. (shrink)

In this paper I am concerned to address the question of voluntary or self‐willed death from two distinct positions—a particular community's socio‐religious practice (viz. Jaina sallekhanā) and as the matter stands in law (penal code, constitution, judicial wisdom, etc.) in India—in the light of the recent move by a bench of its apex court striking down the penal code section proscribing suicide. I also wish to draw out some implications of these deliberations for the beneficence of medical practice and (...) related bio‐ethical ramifications in the Indian context. (shrink)

BackgroundIn Saudi clinical settings, benevolent family care that reflects strongly held sociocultural values is commonly used to justify overriding respect for patient autonomy. Because the welfare of individuals is commonly regarded as inseparable from the welfare of their family as a whole, these values are widely believed to obligate the family to protect the welfare of its members by, for example, giving the family authority over what healthcare practitioners disclose to patients about their diagnoses and prognoses and preventing them from (...) making informed decisions about their healthcare.DiscussionFamily dominance over the healthcare decisions of competent patients is ethically problematic when the family prevent healthcare practitioners from disclosing diagnoses and prognoses to patients who have the capacity to consent and make decisions in their own best interests. Thus, the author holds that sociocultural values ought to be respected only when they do not prevent competent patients from knowing their diagnoses and prognoses or prevent them from making their own decisions.ConclusionHealthcare practitioners should not allow patients’ families to control what can or cannot be disclosed to competent patients. This is particularly important when patients are approaching death so that they may address their material and spiritual wishes—among other needs—as they prepare for death. Justification for this position is drawn from the Maqasid Al-Shariah-based Islamic bioethics approach, from which it is possible to argue that the harm of withholding diagnoses and prognoses from patients who are imminently dying outweighs the potential benefits. (shrink)

In 1992, Eluana Englaro was involved in a car accident in Italy that eventually left her in a permanent vegetative state requiring artificial nutrition and hydration. This paper, after briefly reviewing Eluana's case, gives a chronicle of Eluana last months until her death on 9 February 2009, and discusses the right-to-die controversy in Italy. For many years, Mr Englaro, Eluana's father, would litigate to enforce what he considered to be his daughter's wish to discontinue life-prolonging treatment. In July 2008, (...) the Court of Appeal of Milan has given its authorisation for artificial life support to be withdrawn. This ruling sparked a crusade, led by the government and the Vatican, against the court and Eluana's father, which included insinuations that the latter was murdering his daughter. Public opinion has overwhelmingly been sympathetic to the father's difficult decision, in stark contrast to the reactionary stance taken by the government. With the notable advances of medicine, doctors are increasingly faced with ethical issues. The vegetative state is just one of the many clinical conditions that obligate health professionals to reflect on ethical matters. The withdrawal of life-supporting care, and of artificial nutrition and hydration in particular in permanent vegetative state patients remains a measure which violates a tradition and a consolidated practice. It was thus inevitable that it would create great controversy. We should work towards making a decision process that ensures that continuation or suspension of artificial nutrition and hydration follows an explicit procedure, promoting the sharing and respect of the diverse moral responsibility of family members, nursing and medical staff. (shrink)

Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life as a result of their depressive symptoms when similarly situated (...) incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death. (shrink)

Unlike many philosophers who write on biomedical ethics, John Hardwig is not primarily concerned to test our intuitions about the limits of normative theories by thought experiments or problematic borderline cases. Rather, he presses us to accept the conclusions to which our most firmly held principles commit us. But these conclusions, if Hardwig is right, turn out to be quite startling claims about moral duty that would undermine much of contemporary bioethical theory regarding end-of-life decisions. On his view, we must (...) face squarely the moral implications of our present arrangement of healthcare funding in the United States, where more and more of the financial responsibility of care is being shifted onto the families of patients, often with disastrous results. Yet, in the context of this increasingly unstable arrangement, our chief principle of medical decisionmaking also holds that their interests are not morally relevant at all in deciding what should be done for the patient, and only the patient's wishes count. Now Hardwig thinks that this rule is irrational in the present circumstances, and that it would make more sense to admit the moral relevance of the interests of family members, but also that if we do give appropriate weight to their concerns, we shall be led in some cases to the conclusion that the patient has a duty to die. (shrink)

Health-care professionals in end-of-life care are frequently confronted with patients who seem to be ‘ambivalent’ about treatment decisions, especially if they express a wish to die. This article investigates this phenomenon by analysing two case stories based on narrative interviews with two patients and their caregivers. First, we argue that a respectful approach to patients requires acknowledging that coexistence of opposing wishes can be part of authentic, multi-layered experiences and moral understandings at the end of life. Second, caregivers need (...) to understand when contradictory statements point to tensions in a patient’s moral experience that require support. Third, caregivers should be careful not to negatively label or even pathologize seemingly contradictory patient statements. (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)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this (...) protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

Bioethicists involved in end‐of‐life debates routinely distinguish between ‘killing’ and ‘letting die’. Meanwhile, previous work in cognitive science has revealed that when people characterize behaviour as either actively ‘doing’ or passively ‘allowing’, they do so not purely on descriptive grounds, but also as a function of the behaviour’s perceived morality. In the present report, we extend this line of research by examining how medical students and professionals (N = 184) and laypeople (N = 122) describe physicians’ behaviour in end‐of‐life scenarios. (...) We show that the distinction between ‘ending’ a patient’s life and ‘allowing’ it to end arises from morally motivated causal selection. That is, when a patient wishes to die, her illness is treated as the cause of death and the doctor is seen as merely allowing her life to end. In contrast, when a patient does not wish to die, the doctor’s behaviour is treated as the cause of death and, consequently, the doctor is described as ending the patient’s life. This effect emerged regardless of whether the doctor’s behaviour was omissive (as in withholding treatment) or commissive (as in applying a lethal injection). In other words, patient consent shapes causal selection in end‐of‐life situations, and in turn determines whether physicians are seen as ‘killing’ patients, or merely as ‘enabling’ their death. (shrink)

Advanced directives and living wills have improved our ability to dictate end-of-life care, but even these cannot guarantee that we will be allowed the dignity of a natural death. Designed by two sisters-one a doctor, one a lawyer-and drawing on their decades of experience, the five-step Compassion Protocol outlined in A Better Way of Dying offers a simple and effective framework for leaving caretakers concrete, unambiguous, and legally binding instructions about your wishes for your last days. Meant for people in (...) every walk of life-from the elderly, to those in the early stages of mentally degenerative diseases like Alzheimer's, to healthy young people planning for an unpredictable future-this book creates space for a discussion we all must have if we wish to ensure comfort and control at the end of our lives.." -- from publisher's website. (shrink)

In this paper, I would like to argue that brain-dead small children have a natural right not to be invaded by other people even if their organs can save the lives of other suffering patients. My basic idea is that growing human beings have the right to grow in the form of wholeness, and dying human beings also have the right to die in the form of wholeness; in other words, they have the right to be protected from outside invasion, (...) unless they have declared their wish to abandon that right beforehand. I call this the principle of wholeness. Natural rights, which were discussed by Hobbes and Locke in the 17th century, have to be extended to include the right to grow and die in the form of wholeness in the age of scientific civilization, where peripheral human lives are being threatened by aggressive biomedicine and other advanced technologies. (shrink)

On 26 February 2020, the Federal Constitutional Court of Germany pronounced a judgement that the prohibition of assisted suicide services set out in § 217 of the Criminal Code is void. It thereby reestablished the legal state that had obtained before 2015. Furthermore, it defined the right to die as an autonomy-based right, thereby dissociating the right to take one???s life from states of extreme suffering caused by illness. The judgement implies that one can, in principle, resort to assistance for (...) suicide even in the absence of illness and suffering. In this contribution, I deal with the problems that arise as a consequence of dissociating legitimate assisted suicide from states of illness. I analyze Bettina Schöne-Seifert???s suggestion to regard an understandable (,,nachvollziehbar“) wish to die as a wish that is protected by the right to autonomy. It turns out that the criterion of understandability is deficient: it either commits us to regarding every wish to die as understable or it undermines the anti-paternalistic requirement of respecting the patient???s autonomy. (shrink)

When elderly people are ideating on manners to end their lives, because they feel life is over and no longer worth living, it is important to understand their lived experiences, thoughts and behaviour in order to appropriately align care, support and policy to the needs of these people. In the literature, the wish to die in elderly people is often understood from a medical, psychopathological paradigm, referred to as cognitive impairment, depressive disorder, pathological bereavement, and suicidality. In this paper, (...) we evaluate this dominant paradigm by considering three serious limitations, namely: (1) the risk of epistemic transformation; (2) the risk of reduction; and (3) the risk of obscuring the social and cultural embeddedness. Drawing on insights from our empirical–phenomenological research on the issue of elderly and the self-chosen death, this paper argues for a phenomenological perspective to counteract the medicalisation of death wishes in elderly people. (shrink)

Standard views of good death in human and veterinary medicine considerably differ from one another. Whereas the good death ideal in palliative medicine emphasizes the positive aspects of non-induced dying, veterinarians typically promote a quick and painless killing with the aim to end suffering. Recent developments suggest a convergence of both professions and professional attitudes, however. Palliative physicians are confronted with patients wishing to be ‘put to sleep’, while veterinarians have begun to integrate principles and practices from hospice care. We (...) will argue that the discourses on good human and animal deaths are not distinct, but that they interact and influence each other. On the one hand, veterinary medicine adapts techniques like chemotherapy or sedation from palliative end-of-life care. On the other hand, philosophers, veterinarians, pet owners, patients and the general public alike make certain assumptions about the analogy of human and animal dying or killing. Unfortunately, these interactions have only scarcely been reflected normatively, especially on the part of human medicine. Conflicts and misattributions with potential serious negative consequences for the patients’ wellbeing are provoked. For these reasons, palliative physicians and veterinarians are invited to engage in the debate around human and animal end-of-life care. (shrink)

If you slide far enough down the slippery slope envisioned by opponents of medical assistance-in-dying (MAiD), you eventually land in a ghastly society with industrialized euthanasia, rampant suicide, and devalued life. But what if the slippery slope leads us somewhere better? This paper explores the benefits of eliminating nearly all MAiD prohibitions and regulations. We anticipate three positive effects for public health: 1. Expanded access to those currently not qualified from MAiD by removing ineffective access criteria; 2. Harm reduction by (...) making MAiD safer and by rerouting suicidal patients into alternate care; and 3. Improvements to the health system through lowered healthcare costs and increased patient activation in end-of-life care. Safeguards and prohibitions deny those who wish to die the ability to do so to prevent the _potential_ danger of a few being subjected to an undesired early death. (shrink)

Rising numbers of ageing prisoners and goals on implementing equivalent health care in prison raise issues surrounding end-of-life care for prisoners. The paucity of research on this topic in Europe means that the needs of older prisoners contemplating death in prison have not been established. To investigate elderly prisoners’ attitudes towards death and dying, 35 qualitative interviews with inmates aged 51 to 71 years were conducted in 12 Swiss prisons. About half of the prisoners reported having thought about dying in (...) prison, with some mentioning it in relation with suicidal thoughts and others to disease and old age. Themes identified during data analysis included general thoughts about death and dying, accounts of other prisoners’ deaths, availability of end-of-life services, contact with social relations, and wishes to die outside of prison. Study findings are discussed using Allmark’s concept of “death without indignities,” bringing forth two ethical issues: fostering autonomy and removing barriers. Attributing the identified themes to these two ethical actions clarifies the current needs of ageing prisoners in Switzerland and could be a first step towards the implementation of end-of-life services in correctional systems. (shrink)

This study examined why intensive care unit (ICU) nurses experience difficulties in respecting the wishes of patients in end-of-life care in Japan. A questionnaire survey was conducted with ICU nurses working in Japanese university hospitals. The content of their narratives was analyzed concerning the reasons why the nurses believed that patients' wishes were not respected. The most commonly stated reason was that patients' wishes were impossible to realize, followed by the fact that decision making was performed by others, regardless of (...) whether the patients' wishes were known, if the death was sudden, and time constraints. Many nurses wanted to respect the wishes of dying patients, but they questioned how patients die in ICUs and were therefore faced with ethical dilemmas. However, at the same time, many of the nurses realized that respecting patients' wishes about end-of-life care in an ICU would be difficult and that being unable to respect these wishes would often be unavoidable. The results thus suggest that there has been insufficient discussion about respecting the wishes of patients undergoing intensive care. (shrink)

Prudentius’s hymn on St. Eulalia suffers from an interpolated stanza : the carnifices’s flight caused by the dove, i.e. the soul, leaving the mouth of the dying saint is an exaggeration not found anywhere else in the ancient acts and legends of the Christian martyrs. It disturbs the poem’s composition and violates the tenderness of its poetical invention. The spurious lines, though patched up with material borrowed from the author, show some weakness in expression and offer the problem of differentiating (...) between satelles and lictor, a differentiation that was never made by the poet himself. The forged stanza was made up and included by an interpolator who wished to complete the poem’s storyline specifying a motive which had only been alluded to in the authentic poem. (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)

ABSTRACT Those who wish to refute the view that it is worse to kill than to let die sometimes produce examples of cases in which an agent lets someone die but would be generally agreed to be no less reprehensible than if he had killed. It is argued that the examples produced typically possess a feature which makes their use in this context illegitimate, and that when modified to remove this feature, they provide support for the view which they (...) were designed to undermine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Die Philosophische Logik Gottlob Freges. Ein Kommentar, mit den Texten des Vorworts zu Grundgesetze der Arithmetik und der Logischen Untersuchungen I–IVLeila HaaparantaWolfgang Künne. Die Philosophische Logik Gottlob Freges. Ein Kommentar, mit den Texten des Vorworts zu Grundgesetze der Arithmetik und der Logischen Untersuchungen I–IV. RoteReihe 30. Frankfurt: V. Klostermann, 2010. Pp. 840. Paper, €29.80.Frege’s thought has been a permanent point of interest among philosophers for several decades. In (...) the late sixties a few philosophers, such as Christian Thiel and Ignacio Angelelli, published studies on Frege’s logic, semantics, and metaphysics. In 1973 Michael Dummett’s work on Frege’s philosophy of language appeared, which held the stage for a long time. It presented Frege as a predecessor, even as a representative, of the analytic tradition. New approaches came up in the late 1970s and early 1980s, such as Hans Sluga’s work in 1980 and other studies, which paid special attention to Frege’s German background, where Kant played a significant role. Several scholars, including Michael Dummett, started to dig into Frege’s background. Positions varied; some studied Frege’s background in order to show that there is nothing that could help us understand his philosophical insights; others found the origins of his philosophical and logical ideas precisely in his background and philosophical environment, in such philosophers as Leibniz, Kant, Trendelenburg, and Lotze.After a few somewhat more quiet years, Frege scholarship expanded after 2000. A number of books have appeared that discuss Frege in the analytic context and also seek [End Page 507] to find more details about his philosophical sources. Wolfgang Künne’s work is a most welcome contribution to contemporary scholarship in the field. Lothar Kreiser’s Gottlob Frege: Leben—Werk—Zeit (2001) has already been available, and interpretations of Frege’s philosophy as well as editions and translations of his books contain short biographies. Still, because of its special composition, Künne’s work serves to fill a gap in the scholarship and significantly contributes to what is known about Frege’s logic and philosophy.The volume consists of three parts. First, there is an extensive biography (about 50 pages) of Frege that places Frege’s thought in its historical context and also contextualizes those of his articles that are included in the work. The main projects Frege pursued, most notably the project of logicism, receive proper attention in the first part of the volume. The four texts that are included in the volume are the Preface of the Grundgesetze der Arithmetik I (1893) and the three logical investigations that were published during Frege’s lifetime, namely “Der Gedanke” (1918), “Die Verneinung” (1919), and “Gedankengefüge” (1923), which were originally published in Beiträge zur Philosophie des deutschen Idealismus. Künne has also included a posthumously published text, “Logische Allgemeinheit,” in the volume, as that fragment, which was not written before 1923, was intended to be a fourth logical investigation. The five texts written by Frege that are included in the edition discuss topics that we would now call philosophical logic, such as meaning, reference, and truth, although they also study themes that we would include in ontology and the philosophy of mind. The title of the volume is thus sufficiently motivated.Frege’s texts take up about 100 pages of the volume, while the commentary is about 600 pages. The book also contains an appendix on Bolzano and Frege, where Künne pays attention to similarities between the two logicians and philosophers but also shows his skepticism about the thesis that Frege had read Bolzano. Apart from this position, Künne prefers to read Frege’s texts closely and inform his reader of historical and philological matters rather than take part in any heated debates concerning interpretations; his own positions become visible only indirectly, through the extensive footnotes. The work also contains a very useful bibliography and indexes of names and subjects.The book is extremely rich. If one, for example, wishes to know more about the views of Frege’s German contemporaries, about the standpoints that Russell or Wittgenstein had on Fregean topics, or about the arguments of Frege scholars, one can find... (shrink)

Many people attempt to give meaning to their lives by pursuing projects that they believe will bear fruit after they have died. Knowing that their death will preclude them from protecting or promoting such projects people who draw meaning from them will often attempt to secure their continuance by securing promises from others to serve as their caretakers after they die. But those who rely on such are faced with a problem: None of the four major accounts that have been (...) developed to explain directed promissory obligation (the Authority View, the Trust View, the Assurance View, and the Reliance View) support the view that we are obligated to keep our promises to persons who are now dead. But I will provide hope for those who wish to use such promises to protect the meaning with which they have endowed their lives. I will argue that while we cannot wrong a person who is now dead by breaking a promise made to her during her life, we could wrong the living by so doing. We thus (might) have reason to keep the promises that we made to those who are now dead. (shrink)

Francesca Albertini's voluminous study, Die Konzeption des Messias bei Maimonides und die fruehmittelalterliche islamische Philosophie, wishes to put a fresh emphasis on the link between Maimonides' concept of the Messiah and his ideal of the leader as a political figure. For Maimonides, Albertini argues, the arrival of the Messiah will be realized only through human effort and appropriate behavior: it is man who bears responsibility for this event through his moral actions. The Messiah, on the other hand, as the leader (...) of the community, seeks to implement the new order in society through which Divine Law will be established and followed precisely. Hence, the Messiah's arrival is not an apocalyptic, eschatological .. (shrink)

We wish to describe and acknowledge the exceptional contributions to medical ethics, both in the UK and internationally, made by Edward Shotter1 who died at home on 3 July 2019. He was founder of the London Medical Group2 3 and instigator of similar student-led medical ethics groups throughout the UK; founder of the Institute of Medical Ethics4 and founder of the Journal of Medical Ethics. Ted Shotter transformed the study of medical ethics in the UK in the interests of (...) patients and professionals alike. In 1963, he established the pioneering ‘Medical Group’ model, an innovative bottom-up method whereby students in the health professions could gain a grounding in ethics that had previously been denied to the profession.5 It was with these Medical Groups that many of the leading figures in contemporary UK medical ethics and law began their careers in the subject including Sir Kenneth Calman, Sir Ian Kennedy, Professor Margaret Brazier OBE, Professor John Harris and Professor Sir Jonathan Montgomery to name but …. (shrink)

The article analyzes the world of transience, deterioration and death characteristic of Boghill, the place of action of Samuel Beckett’s short radio play-All That Fall. In a broadcast drama, existence is equivalent to being heard, the idea skilfully employed and commented upon by the playwright. The characters actually heard in the play are in most cases elderly or quite old and even the two young ones appear in the context of death. Numerous off-the-air individuals are dead, sterile or suffering from (...) different illnesses. The two main characters’ situation is not different-Mr Rooney is blind, and his wife, Maddy, complains of many ailments. She is a woman in her seventies, overweight and having different kinds of health problems and thus, several times in the course of the play she expresses a wish to die. At the same time, however, in encounters with men on her way to the station she speaks in a manner characterized by numerous sexual innuendos. Furthermore, she expresses a strong yearning for love and hopes her unloving husband would show her some warm feelings. Thus she becomes a convincing illustration of Georges Bataille’s argument: “Eroticism, it may be said, is assenting to life up to the point of death”. (shrink)

Schuklenk and van de Vathorst's paper is a very welcome addition to the literature on the assisted dying debate and will be of great interest to clinicians working in the field of mental health.1 Many psychiatrists will have had patients who have asked them to allow them to die, to desist in their efforts to prevent their suicide, and one of us has had personal experience, outside of professional life, of being asked to aid in someone's attempt to end their (...) life in the context of an episode of mood disorder. The person with depression asking professionals, friends and family members to aid them in ending their life is a very real phenomenon. In their discussion, Schuklenk and van de Vathorst's paper uses two principles that we endorse and add weight to their argument: namely, the reality of suffering in depression and the parity of mental and physical illness. Indeed, the case Schuklenk and van de Vathorst make is a strong one and our commentary will focus on the premise of the argument around choosing death and some empirical clarification about competence in depression and the nature of treatment-resistant depression (TRD) and its prognosis. The conceptual concern we wish to discuss in relation to assisted dying, endorsed by the state and legislature, is not linked to any moral or religious concern, or even on grounds related to ‘slippery slope’ or ‘abuse’ arguments. Rather the worry is how one could operationalise decisions around assisted dying as based on competence and capacity and view such decisions as rational. I think this concern is not limited to depressive illness, but to all decisions regarding choosing non-existence. Schuklenk and van de Vathorst offer the following useful criteria to regulate assisted suicide:1. (shrink)

The public debate on voluntary termination of life by elderly people, which has been an intensely controversial subject in the Netherlands for some time, has centered around the issue of “completed life” in recent years. In 2016, an ad hoc governmental advisory committee concluded that the already existing Euthanasia Act provided sufficient scope to resolve most of the problems related to the issue. Most of the older adults who feel they no longer have anything to look forward to in their (...) lives and who have developed a wish to die as a result would be able to invoke this Act. Partly for this reason, the committee considered broadening the legal options relating to assisted suicide undesirable. Analysis of the assessment practice of the regional euthanasia review committees reveals that the room for interpretation offered by the Euthanasia Act is indeed considerable. (shrink)