Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the (...) ethical analysis is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

It may seem that epistemic and practical rationality weigh reasons differently, because ties in practical rationality tend to generate permissions and ties in epistemic rationality tend to generate a requirement to withhold judgment. I argue that epistemic and practical rationality weigh reasons in the same way, but they have different "default biases". Practical rationality is biased toward every option being permissible whereas epistemic rationality is biased toward withholding judgment's being required.

Several authors have recently endorsed the thesis that there is what has been called pragmatic encroachment on knowledge—in other words, that two people who are in the same situation with respect to truth-related factors may differ in whether they know something, due to a difference in their practical circumstances. This paper aims not to defend this thesis, but to explore how it could be true. What I aim to do, is to show how practical factors could play a role in (...) defeating knowledge by defeating epistemic rationality—the very kind of rationality that is entailed by knowledge, and in which Pascalian considerations do not play any role—even though epistemic rationality consists in having adequate evidence. (shrink)

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, (...) consequentialist and virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. (shrink)

In “Postponed Withholding: Balanced Decision-Making at the Margins of Viability,” Syltern et al. (2022) propose a novel approach to life-and-death decision making for extremely preterm infants in t...

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated (...) entails a claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored. (shrink)

The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged (...) too futile to offer. They thus retain greater decision-making burden and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made. (shrink)

This paper presents a puzzle about justification and withholding. The puzzle arises in a special case where experts advise us to not withhold judgment. My main thesis is simply that the puzzle is genuinely a puzzle, and so leads us to rethink some common assumptions in epistemology, specifically assumptions about the nature of justification and doxastic attitudes. Section 1 introduces the common assumptions. Section 2 presents the puzzle case. Section 3 assesses the puzzle case. Section 4 explains the choice (...) we're faced with. Sections 5 and 6 consider and reject some proposed solutions, and in the process refine and clarify the choice we're faced with. Section 7 considers and rejects a miscellany of different proposed solutions. (shrink)

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support int...

This paper argues that Sulmasy and Sugarman have not succeeded in showing a moral difference between withholding and withdrawing treatment. In particular, they have misunderstood historical entitlement theory, which does not automatically prefer a first occupant by just acquisition.

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant’s prognosis and the burdens of continued treatment. (...) Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life. (shrink)

Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments. The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units. Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, (...) legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of. Most respondents were between 30 and 49 years old, Catholic Christians, anesthesiologists, working in Beirut. Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect”. The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary, involving the family, and the patient, or his advance directives or his surrogate and the nurses. The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices. Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country. (shrink)

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating (...) suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (shrink)

This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role of the family in management is discussed. This issue requires wide debate by the public and the profession.

PurposeScarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting.Materials and methodsA prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire.Results8 (25%) physicians and 24 (75%) nurses participated in (...) the study by providing their ‘treatment decisions’ for 14 patients at several time points. EOLD was ‘made’ 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment.ConclusionsOur findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 70-72, December 2011.

The topic of withholding the Heimlich maneuver as part of a do-not-attempt-to-resuscitate (DNAR) order or an advance directive has not been widely discussed in the clinical ethics literature. This discussion addresses a request by family members to withhold the Heimlich maneuver from a patient in a long-term care facility. A request to forgo the Heimlich maneuver seems to have prima facie categorical similarities to justifications for withholding lifesaving treatments such as cardiopulmonary resuscitation (CPR). Further examination reveals significant distinctions. (...) Such distinctions call into question the ethical appropriateness of including the Heimlich maneuver among interventions to be withheld as part of end-of-life care planning, and encourages a broader discussion of an increasingly uncritical deference to autonomy in end-of-life decision making. Most notably, the Heimlich maneuver is the only intervention known to effectively relieve the distressing symptoms of accidental choking. The Heimlich maneuver serves a palliative function and is the standard of care for accidental choking. The Heimlich maneuver should not be conflated with other life-prolonging interventions that may be withheld as part of end-of-life care planning. (shrink)

Withholding and pursuit are well-documented phenomena in talk between adults and in talk with children. They have been described as working to perform various functions that emerge locally between speakers in a variety of interactional contexts both in ordinary conversation and in institutional talk.In this paper I explore further the actions of pursuit and withholding in interaction between parents and their very young children, first described in Filipi (2003, 2009) by going beyond description and by examining how these (...) features might be implicated in learning. Longitudinal change is thus a focus of the analysis. Examples of talk are drawn from one child aged from 11 to 24 months interacting with members of her family.Applying the microanalytic approach of Conversation Analysis, the study reports four contexts in which pursuit emerges as an important resource. They are pursuit relevant to sequence structure, linguistic pursuit, pursuit of understanding and pursuit of a particular response token. Analysis shows that while the adults orient to the need to move the action forward, particularly observable in the Summons/Response adjacency pair, withholding of completion can occur at any time in order for parent and child to work on particular skills. Finally, I argue that the micro details of the actions of withholding and pursuit provide a particularly useful lens with which to observe the dynamic qualities of asymmetry. Keywords: parent child interaction; Conversation Analysis; language development; asymmetry; withholding; pursuit. (shrink)

Withholding and pursuit are well-documented phenomena in talk between adults and in talk with children. They have been described as working to perform various functions that emerge locally between speakers in a variety of interactional contexts both in ordinary conversation and in institutional talk.In this paper I explore further the actions of pursuit and withholding in interaction between parents and their very young children, first described in Filipi by going beyond description and by examining how these features might (...) be implicated in learning. Longitudinal change is thus a focus of the analysis. Examples of talk are drawn from one child aged from 11 to 24 months interacting with members of her family.Applying the microanalytic approach of Conversation Analysis, the study reports four contexts in which pursuit emerges as an important resource. They are pursuit relevant to sequence structure, linguistic pursuit, pursuit of understanding and pursuit of a particular response token. Analysis shows that while the adults orient to the need to move the action forward, particularly observable in the Summons/Response adjacency pair, withholding of completion can occur at any time in order for parent and child to work on particular skills. Finally, I argue that the micro details of the actions of withholding and pursuit provide a particularly useful lens with which to observe the dynamic qualities of asymmetry. Keywords: parent child interaction; Conversation Analysis; language development; asymmetry; withholding; pursuit. (shrink)

According to Jewish law, to make a judgment that a life has no purpose and is not worth saving is contrary to the concept of justiceTraditional medical practice dictates that when patients are unable to eat or drink enough to sustain their basic nutritional requirements, artificial feeding and hydration is indicated. Common clinical examples of this problem are patients with senile dementia and those in a persistent vegetative state . In recent decades, however, the practice of mandating artificial feeding has (...) been increasingly questioned. A combination of legal, ethical, and clinical considerations has resulted in broad support for withholding and withdrawing artificial nutrition. The guiding ethical principle in the current clinical standards is that patient autonomy must be honoured. In the context of an incompetent adult , advance directives or surrogate decision making are legally binding. Such requests to withhold artificial nutrition are considered appropriate and even encouraged.1 Such a view, however, is not unanimous. For example, Catholic writers have questioned the current consensus. The New Jersey Catholic Conference has written that withholding nutrition and hydration from such patients “ultimately results in starvation, dehydration, and death,” and that withdrawing such basic care from patients who are not dying but in a PVS “is a clear statement that the patient’s life has no moral value”.2 This question is also of great concern in Jewish law . In contrast to secular medical ethics, halachah requires that artificial feeding be given to patients with dementia or in a PVS. The following discussion gives an overview of the pertinent arguments that have led to the consensus in secular ethics that artificial feeding may be withheld from the severely demented and the halachic considerations that argue against this practice.CLINICAL ARGUMENTS IN FAVOUR OF WITHHOLDING ARTIFICIAL FEEDINGThe most obvious …. (shrink)

In cases of sudden, life-threatening illness where the chance of survival appears negligible to the admitting physician, this opinion is not always revealed during the initial meeting with the patient's relatives. Reasons as to why this withholding of the truth may be acceptable are explored through review of available evidence and personal reflection. Factors identified include: the importance of hope in families' coping mechanisms, and the instinct to preserve it; the fallibility of physicians' perception of poor prognosis in the (...) early phase of illness; the need to avoid large swings in relatives' expectations that occur when patients appear to rally during initial resuscitation; and the adverse effect that an atmosphere of hopelessness can have on the provision of medical care. A strategy for the staged disclosure of information and the confirmation of hopelessness is then described, the aim being to find a compromise between providing a true opinion about a patient's prognosis, and regard for the opposing factors described. (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. (...) Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Counseling parents on the cusp of delivering an extremely preterm infant is performed thousands of times every year in North America, Europe, Japan and in centers situated in other countries around...

The author reviews and continues the debate initiated by her recent paper in this journal. The paper was critical of certain aspects of palliative medicine, and caused Ashby and Stoffell to modify the framework they proposed in 1991. It now takes account of the need for artificial hydration to satisfy thirst, or other symptoms due to lack of fluid intake in the terminally ill. There is also a more positive attitude to the emotional needs and ethical views of the patient's (...) family and care-givers. However, clinical concerns about the general reluctance to use artificial hydration in terminal care remain, and doubts persist about the ethical and legal arguments used by some palliative medicine specialists and others, to justify their approach. Published contributions to the debate to date, in professional journals, are reviewed. Key statements relating to the care of sedated terminally ill patients are discussed, and where necessary criticised. (shrink)

Patients who are dying of cancer usually give up eating and then stop drinking. This raises ethical dilemmas about providing nutritional support and fluid replacement. The decision-making process should be based on a knowledge of the risks and benefits of giving or withholding treatments. There is no clear evidence that increased nutritional support or fluid therapy alters comfort, mental status or survival of patients who are dying. Rarely, subcutaneous fluid administration in the dying patient may be justified if the (...) family remain distressed despite due consideration of the lack of medical benefit versus the risks. Some cancer patients who are not imminently dying become dehydrated from reversible conditions such as hypercalcaemia. This may mimic the effects of advanced cancer. These conditions should be sought and fluid replacement therapy should be given along with the specific treatments for the condition. (shrink)

The extremely preterm infant, born before 28 weeks of gestational age, has been the focus of much ethical discussion. These infants have a significant risk of mortality and morbidity, and it is not...

Syltern et al. (2022) propose a new approach to decision-making at the limit of viability: by default, intensive care will be initiated for every infant born in “the gray zone” of viability. This w...

This paper examines public meetings in the Netherlands where experts and officials interact with local residents on the human health effects of livestock farming. Using Conversation Analysis, we reveal a ‘weapon of the weak’: a practice by which the residents resist experts’ head start in information meetings. It is shown how residents draw on the given question-answer format to challenge experts and pursue an admission of, for example, methodological shortcomings. We show how the residents’ first question functions as a ‘foot-in-the-door’, (...) providing them with a strong basis for skepticism. By systematically challenging the expert responses, the residents exploit the interaction’s sequential organization, with the effect that the goal becomes them being convinced rather than being informed. Consequently, the withholding of consent becomes the residents’ ‘weapon’. Finally, we argue that in an age where expertise is increasingly contested, it is crucial to understand how, and to what end, this contestation may occur. (shrink)

This special issue, Withholding artificial nutrition and hydration, comprises several papers, commentaries and responses centred largely around the issues raised by the 2011 decision of the English Court of Protection in W v M.i In that case, the mother of an adult patient applied for the withdrawal of life-sustaining treatment . In 2003, the patient, M, had contracted viral encephalitis and suffered irreparable brain damage as a result. She fell into a coma, and when she emerged appeared to be (...) in a vegetative state and for 8 years was entirely dependent on life-sustaining care.Following her mother's application, M was held to lack capacity and hence in accordance with section 4 of the Mental Capacity Act 2005 , the matter turned on whether it was in her best interests for the treatment to be withdrawn. It was made clear in the 1993 decision of Airedale NHS Trust v Bland that life-sustaining treatment could be withdrawn from a patient in a permanent vegetative state if, on balance, it was not in his or her interest to continue treatment.ii The MCA also allows for withdrawal of treatment, although the approach to best interests is slightly different. However, the case of W v M is importantly different from the Bland case, because M was found not to be in a PVS, but instead was minimally conscious . Much evidence was presented of her capacity to respond to stimuli, seemingly express emotion and occasionally speak.In the first of his papers in this issue , Julian Sheather provides an overview of the case, particularly illuminating the discussions of M's interests and the views of her …. (shrink)

Objectives: To compare non-treatment decision making by general practitioners and geriatricians in response to vignettes. To see whether the doctors’ decisions were informed by ethical or legal reasoning.Design: Qualitative study in which consultant geriatricians and general practitioners randomly selected from a list of local practitioners were interviewed. The doctors were asked whether patients described in five vignettes should be admitted to hospital for further care, and to give supporting reasons. They were asked with whom they would consult, who they believed (...) ought to make such decisions, and whether the relatives’ preferences would influence their decision making.Main measures: To analyse the factors influencing the doctors’ decisions not to admit otherwise terminally ill patients to hospital for life prolonging treatment.Results: Seventeen GPs and 18 geriatricians completed the interview. All vignettes produced strong concordance in decision making between both groups. Ten per cent of the doctors would provide life prolonging treatment to patients with severe brain damage. Most would admit a surgical patient regardless of age or disability. Medical reasons were largely used to explain decision making. The wishes of relatives were influential and resource considerations were not. There was variability regarding decision making responsibility.Conclusions: Little attempt was made to link decision making with ethical or legal concepts and there may have been non-recognition, or denial, of the ethical consequences of failure to admit. The process of decision making may involve deception. This may be conscious, because of the illegality of euthanasia, or unconscious , because of deepseated medical and societal reluctance to accept that intentionally withholding life prolonging treatment may equate with intentionally causing death. (shrink)

Purpose: To determine motives and attitudes towards life-sustaining treatments by clinical and preclinical medical students. Methods: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. Results: (...) Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury. In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. Discussion: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented. (shrink)

Volume 19, Issue 6, June 2019, Page W5-W9.

Recent years have seen the rise of fittingness-first views, which take fittingness to be the most basic normative feature, in terms of which other normative features can be explained. This paper poses a serious difficulty for the fittingness-first approach by showing that existing fittingness-first accounts cannot plausibly accommodate an important class of reasons: reasons not to believe a proposition. There are two kinds of reasons not to believe a proposition: considerations that are counterevidence; and considerations that count against believing the (...) proposition without indicating that it is false. I will argue that the fittingness- first accounts have trouble accommodating reasons of the latter kind. (*published with open access). (shrink)

BackgroundThere has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. MethodsA cross-sectional study was conducted on a three-stage random sample of adult citizens (...) of the Republic of Croatia, stratified by regions, counties, and locations within those counties. In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis, correlation analysis and multiple regression analysis for data analysis.Results38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures.ConclusionsThe study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. (shrink)

Parents respond to the death of a child in very different ways. Some parents may be violent or angry, some sad and tearful, some quiet and withdrawn, and some frankly delusional. We present a case in which a father’s reaction to his daughter’s death is a desire to protect his wife from the stressful information. The wife is in the second trimester of a high-risk pregnancy and so is particularly fragile. We asked pediatricians and bioethicists to discuss the ways in (...) which they might respond to the father’s understandable but troubling request. -/- The death of a young child is one of the most stressful events that can happen to parents. The stress of such a loss is compounded if the parents are in a foreign country, far from home, and without a network of family and friends to provide social support. The stress may be more difficult to deal with if the parents have acute health problems of their own. In this month’s “Ethics Rounds,” we present a case in which a father whose daughter died requested that the doctors delay telling his wife. His reason: She is pregnant, in the second trimester, and on bed rest because of preterm labor. He does not want to add to her stress. We asked both pediatricians and bioethicists to respond to this request. (shrink)

In this article, I describe and analyse the proposed new International Committee of Medical Journal Editors form for disclosing conflicts of interest and conclude that it has many flaws. The form does not mention ‘conflicts of interest’ even once in either its body or its title, it introduces a conceptually confused categorisation of different potential conflicts and it ignores future conflicts and intellectual biases. Finally, many of the authors of the new form have themselves failed to declare relevant potential conflicts (...) of interest. (shrink)

Competent patients have considerable legal authority to control life‐and‐death care. They may refuse medical life support, including medically delivered food and fluids. Even when they are not in need of any life‐saving care, they may expedite death by refusing food and water by mouth—voluntarily stopping eating and drinking, or VSED. Neither right is limited to terminal illness. In addition, in four U.S. states, competent patients, if terminally ill, may obtain lethal drugs for aid‐in‐dying.For people who have dementia and are no (...) longer competent, however, control over the end of life is much less extensive. They may have written a clear advance directive for refusing life‐saving care in specified circumstances yet subsequently find themselves living for years in severe dementia with no need for life‐saving care that could be refused. Chronic progressive dementia is not itself life threatening until its very final stage. Even in jurisdictions that permit active aid‐in‐dying, individuals with advanced dementia are not eligible; they lack the required current competence, and they are seldom deemed terminally ill. As for the right to VSED, its very name—voluntarily stopping eating and drinking—is seen as excluding noncompetent persons.One option for ensuring that one does not live years in severe dementia is to use advance directives to withhold food and water by mouth. The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment. Thus, if incompetent people do not lose their rights to refuse life‐saving treatment, and if people when competent have just as strong a right to VSED as they do to refuse life‐saving treatment, then people do not lose their right to VSED when incompetent either. They only have to exercise it by AD. (shrink)