Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia.

The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 15 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been refuted in this context.

The Pope and the Possibilities of the Path Less Traveled.

Pope Francis's Address to the participants of the conference "Yes to Life! Taking Care of the Precious Gift of Life in Its Frailty" powerfully touches on multiple important aspects of the care of children experiencing "extreme frailty." It is a deeply moral account of the challenges that health-care providers, families, and patients confront in the technologically sophisticated and confusing world of modern medicine. This commentary draws upon a clinical case to contextualize the Pope's words in the hope of achieving a nuanced understanding of what pediatric palliative care offers to children experiencing extreme frailty. In his Address, the Pope asks health-care providers to consider an approach to frailty and suffering that allows for the opportunity to experience transcendent meaning and transpersonal value, and recognizes that it would be difficult to achieve these goals without the comprehensive and capable care offered by pediatric palliative care specialists.

Orthotanasia and dignified death in cancer patients: The perception of health professionals / Ortotanasia y muerte digna en pacientes con cáncer: La percepción de los profesionales de la salud

Objective: to analyze the perception about dignified death and orthothanasia in the view of health professionals who provide curative and palliative care in oncology. Method: this is a research with exploratory, qualitative approach. Saturation criteria included the participation of eight health professionals from the Cancer Institute of Ceará, Brazil: a physician, a nurse, a social worker and a psychologist of the palliative care team, and an oncologist, a nurse, a social worker and a psychologist of the curative care team. Three instruments were used: semi-structured interview; Free Word Association Test (WAT) with "cancer" and "orthothanasia" as inductive stimulus; and a Photo Projection Test (PPT) using five images. A textual analysis was carried out using the Iramuteq software to analyze the interviews. For the analysis of the WAT, the frequencies of the words of each stimulus were counted; then they were submitted to the word reduction technique and understood through simple frequency analysis. For the analysis of the PPT, the frequencies were counted, followed by analysis of meanings. Results: cancer is perceived by professionals as synonymous with death, pain and suffering, and orthothanasia as a practice of care and affection. The importance of the transition from curative care to exclusive palliative care is evident when there is no prognosis of cure, so as to offer quality of death and pain relief. This process can be facilitated by the acceptance of death and participation on the part of the family. The family must also receive care. Conclusion: health professionals recognize the importance and challenges of orthothanasia

Objetivo: el presente artículo objetivó analizar la percepción sobre la muerte digna y la ortotanasia para los profesionales de salud de cuidado curativo y paliativo en oncología. Método: se realizó una investigación descriptiva y exploratoria de abordaje cualitativo. Se contó con la participación de ocho profesionales de salud del Instituto del Cáncer de Ceará, en Brasil: médico, enfermera, asistente social y psicóloga del equipo de cuidados paliativos, y médico oncólogo, enfermera, asistente social y psicóloga del equipo de cuidados curativos. Se utilizaron tres instrumentos: entrevista semiestructurada, Prueba de Asociación Libre de Palabras (TALP) y Prueba de Proyección sobre Fotos (TPF). Las entrevistas fueron analizadas a través del software Iramuteq. Para el análisis del TALP, las palabras de cada estímulo fueron analizadas y contabilizadas las frecuencias; a continuación, fueron sometidas a la técnica de reducción de palabras y comprendidas por medio de análisis simple de frecuencia. Para el análisis del TPF, se contabilizaron las frecuencias, seguidas de sus análisis de significados. Resultados: los resultados muestran que el cáncer se percibe como sinónimo de muerte, dolor y sufrimiento; y ortotanasia como cuidado y afecto. Se evidencia la necesidad de la aceptación de la muerte y del cambio de enfoque de cuidado de pacientes en proceso de finitud, y que por medio de los cuidados paliativos es posible ofrecer calidad de muerte y alivio del dolor. Conclusión: se concluye que los profesionales de la salud reconocen la importancia y los desafíos de la ortotanasia

The psychological slippery slope from physician-assisted death to active euthanasia: a paragon of fallacious reasoning.

In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common logical argument regularly employed against these practices is the "slippery slope argument." One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a "slippery slope" into acceptance of active euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that warp a society's values and moral perspective of a practice over an extended period of time. This formulation is known as the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that practice physician-assisted death and/or euthanasia, the paper argues that (1) employing the psychological slippery slope argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice, and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death.

[Assessing unbearable suffering in relation to euthanasia]. / Beoordeling ondraaglijk lijden bij euthanasieverzoek.

Dutch law permits physicians to perform euthanasia, provided they fulfil six criteria of due care. Prominent among these is the requirement that they are convinced that the patient is suffering unbearably. But how can they be sure of that? The problem seems to be that this criterion is too subjective on two scores: it makes the patient dependent on the empathic capacities of his physician, and it would be arrogant for the physician to deny that the patient is suffering unbearably if that is what the patient tells them. In this paper I suggest that this criterion is far less arbitrary than it seems.

Pediatric Euthanasia and Palliative Care Can Work Together.

Since the Netherlands produced the Groningen protocol describing the methods to be used for pediatric euthanasia and Belgium passed laws authorizing euthanasia for children who consent to it, the issue of pediatric euthanasia has become a relevant topic to discuss. Most rejections of pediatric euthanasia fall into 1 or more of 3 categories, each of which has problems. This article shows how several recent arguments against pediatric euthanasia fail to prove that pediatric euthanasia is unacceptable. It does not follow from this that the practice is permissible but rather that if one is to reject such a practice, stronger arguments will need to be made, especially in countries where adult euthanasia or assisted suicide is already permitted.

Nursing staff and euthanasia in the Netherlands. A nation-wide survey on attitudes and involvement in decision making and the performance of euthanasia.

OBJECTIVES: To give insight into Dutch nursing staff's attitudes and involvement regarding euthanasia. METHODS: The sample was recruited from a nation-wide existent research panel of registered nurses and certified nursing assistants. Descriptive analyses and multivariate logistic regression analyses were performed. RESULTS: 587 respondents (response of 65%) completed the questionnaire. The majority (83%) state that physicians have to discuss the decision about euthanasia with the nurses involved. Besides, 69% state that a physician should discuss a euthanasia request with nurses who have regular contact with a patient. Nursing staff who have religious or other beliefs that they consider important for their attitude towards end-of-life decisions, and staff working in a hospital or home care, are most likely to have this opinion. Being present during the euthanasia is quite unusual: only a small group (7%) report that this has ever been the case in their entire working life. Seven% (incorrectly) think they are allowed to administer the lethal drugs. CONCLUSION: The majority want to be involved in decision-making processes about euthanasia. Not all are aware that they are not legally allowed to administer the lethal drugs. PRACTICE IMPLICATIONS: Nursing staff should be informed of relevant existing legislation and professional guidelines.

When Physicians Report Having Used Medical Drugs to Deliberately End a Patient's Life: Findings of the "End-of-Life in France" Survey.

CONTEXT: The debate on the decriminalization of active assistance in dying is still a topical issue in many countries where it is regarded as homicide. Despite the prohibition, some physicians say they have used drugs to intentionally end a patient's life. OBJECTIVES: To provide some empirical grounding for the ongoing debate. METHODS: Using data from the End-of-Life in France survey (a representative sample of 15,000 deaths that occurred in December 2009, questionnaires completed anonymously by the physicians who had certified the deaths), we selected all the cases where the physician had used one or more drugs to intentionally end a patient's life and compared the decisions and decision-making process with the conditions imposed by the French law for decisions to withhold or withdraw life-supporting treatments and by the Belgian law on euthanasia. RESULTS: Of the 36 cases analyzed, four situations seemed to be deliberate acts after explicit requests from the patients, and only two seemed to fulfill the eligibility and due care conditions of the Belgian euthanasia law. Decisions made without any discussion with patients were quite common, and we observed inadequate labeling, frequent signs of ambivalence (artificial feeding and hydration not withdrawn, types of drug used), and little interprofessional consultation. Where the patient had requested euthanasia, the emotional burden on the physician was heavy. CONCLUSION: These findings underscore the pressing need for a clarification of the concepts involved among health professionals, patients, and society at large, and better training and support for physicians.

[Assessment of euthanasia request by SCEN physicians]. / Beoordeling van euthanasieverzoek door SCEN-artsen.

OBJECTIVE: To determine how uniformly Support and Consultation on Euthanasia in the Netherlands (SCEN) doctors assess a euthanasia request in patients not in the final stages of a terminal illness. DESIGN: Qualitative research. METHOD: Internal survey among SCEN doctors in the 'SCEN-Drenthe' peer group, who were asked to provide an opinion on the requirements of due care, items a to d, of the Termination of life on request and assisted suicide act (WTL) in three fictitious patients. RESULTS: Sixty assessments were received from 20 SCEN physicians. Half of the reviews were assessed as 'due care requirements not met". 45% of these were for a patient whose request was based on the grounds of a "completed life", 50% for a patient with Alzheimer's, and 55% for a patient with a reduced level of consciousness. Uncertainty about the place of Article 2.2 of the WTL, personal assessment of the unbearable nature of hopeless suffering and the rejection of alternative solutions were responsible for the heterogeneous assessments. CONCLUSION: Uniformity of assessment is important to avoid legal disparity in this patient group. We found no medical or ethical benchmarks for determining the unbearable nature of suffering. A verifying assessment by the SCEN physician can only provide an opinion regarding the presence of hopeless pain that is classified as "unbearable". A negative SCEN assessment undermines a person's sense of justice at a difficult time, while the hopeless suffering may well be accepted as unbearable in comparable cases. Adapting the KNMG "Guidelines on euthanasia for patients in a state of reduced consciousness" so that they are in line with the WTL could also contribute to greater uniformity.

Comparing end-of-life practices in different policy contexts: a scoping review.

OBJECTIVES: End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts. METHODS: This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review. RESULTS: In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors' adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts. CONCLUSIONS: It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.

QALYs, euthanasia and the puzzle of death.

This paper considers the problems that arise when death, which is a philosophically difficult concept, is incorporated into healthcare metrics, such as the quality-adjusted life year (QALY). These problems relate closely to the debate over euthanasia and assisted suicide because negative QALY scores can be taken to mean that patients would be 'better off dead'. There is confusion in the literature about the meaning of 0 QALY, which is supposed to act as an 'anchor' for the surveyed preferences on which QALYs are based. In the context of the debate over euthanasia, the QALY assumes an ability to make meaningful comparisons between life-states and death. Not only is this assumption questionable, but the ethical debate is much more broad than the question of whether death is preferable to a state of living. QALYs are derived from preferences about health states, so do not necessarily reflect preferences about events (eg, dying) or actions (eg, killing). This paper presents a new kind of problem for the QALY. As it stands, the QALY provides confused and unreliable information when it reports zero or negative values, and faces further problems when it appears to recommend death. This should preclude its use in the debate over euthanasia and assisted suicide. These problems only apply where the QALY involves or seems to involve a comparison between life-states and death, and are not relevant to the more general discussion of the use of QALYs as a tool for comparing the benefits derived from treatment options.

[Attitudes towards euthanasia: The impact of experiencing end-of-life care]. / Einstellungen zur Sterbehilfe.Welchen Einfluss hat die Pflege eines sterbenskranken Angehörigen?

BACKGROUND: It is a matter of debate whether euthanasia should be part of medical practice. OBJECTIVES: The current study investigates the attitudes of bereaved family members of cancer patients towards euthanasia. MATERIALS AND METHODS: We conducted a survey with 211 people who had recently lost a close relative to cancer. Participants were asked whether euthanasia should be part of medical practice.Two logistic regression models were calculated in order to determine the factors influencing the attitude towards active euthanasia and assisted suicide. RESULTS: About 70% and 75% of the respondents approved active euthanasia and assisted suicide, respectively. Religious denomination and psychological distress had a significant impact on the attitude towards active euthanasia. About 10%of the deceased patients had asked for active euthanasia. CONCLUSIONS: There was no difference between bereaved family members and the general population regarding the acceptance of euthanasia. Attitudes towards active euthanasia are associated with psychological distress and shaped by cultural values rather than by the experience of end-of-life care.

The acceptability among young Hindus and Muslims of actively ending the lives of newborns with genetic defects.

AIM: To explore the views in non-Western cultures about ending the lives of damaged newborns. METHOD: 254 university students from India and 150 from Kuwait rated the acceptability of ending the lives of newborns with genetic defects in 54 vignettes consisting of all combinations of four factors: gestational age (term or 7 months); severity of genetic defect (trisomy 21 alone, trisomy 21 with serious morphological abnormalities or trisomy 13 with impending death); the parents' attitude about prolonging care (unknown, in favour or opposed); and the procedure used (withholding treatment, withdrawing it or injecting a lethal substance). RESULTS: Four clusters were identified by cluster analysis and subjected to analysis of variance. Cluster I, labelled 'Never Acceptable', included 4% of the Indians and 59% of the Kuwaitis. Cluster II, 'No Firm Opinion', had little variation in rating from one scenario to the next; it included 38% of the Indians and 18% of the Kuwaitis. In Cluster III, 'Parents' Attitude+Severity+Procedure', all three factors affected the ratings; it was composed of 18% of the Indians and 16% of the Kuwaitis. Cluster IV was called 'Severity+Parents' Attitude' because these had the strongest impact; it was composed of 40% of the Indians and 7% of the Kuwaitis. CONCLUSIONS: In accordance with the teachings of Islam versus Hinduism, Kuwaiti students were more likely to oppose ending a newborn's life under all conditions, Indian students more likely to favour it and to judge its acceptability in light of the different circumstances.

Israeli Dying Patient Act: physician knowledge and attitudes.

OBJECTIVES: The recently enacted Israeli Dying Patient Act was designed to strike balance between enhancing patient autonomy in end-of-life decision making and cultural/religious norms that are in opposition to active euthanasia and physician-assisted suicide (PAS). The current study evaluated physician attitudes regarding active and passive euthanasia, and their knowledge of specific aspects of the law. METHODS: A survey was administered to a convenience sample of hospital-based physicians treating terminal patients. Physicians were queried about their attitudes regarding euthanasia and PAS. Physicians were also queried about specific aspects of the law and whether they had sufficient resources to uphold the law. RESULTS: Surveys were distributed to 270 physicians and 100 were returned and evaluated (37%). Nearly all physicians supported passive euthanasia (withholding treatment), whereas over 40% maintained that active forms of euthanasia should be allowed for terminal patients in severe physical pain. Multivariate analysis showed a negative relationship between support for more active forms of euthanasia and physicians' self-reported religiosity. Physicians cited lack of time as a reason for not complying with the new law. Physicians had a familiarity with the general aspects of the new legislation, but a large proportion was not aware of the specifics of the law. CONCLUSIONS: Compared with previous surveys, a larger number of physicians support passive euthanasia. A sizable percentage of physicians would be willing to participate in active euthanasia and even PAS. Attitudes toward euthanasia are influenced by religious factors.