Article

Seven deaths in Darwin: case studies under the Rights of the Terminally III Act, Northern Territory, Australia

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Abstract

During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally Ill (ROTI) Act; four died under the Act. We report their clinical details and the decision-making process required by the Act. We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner. All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed. Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

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... Australia entered into world history in 1995, when the Northern Territory Parliament passed the Rights of the Terminally Ill Act 1995 (hereafter called ROTTIA), legalising voluntary assisted dying (VAD) in Australia [1]. Just months before this, on 25 March 1995, seven doctors in the state of Victoria went public, announcing that they had all been engaging in VAD-illegally, as there was no VAD legislation in Victoria at that time-and called for a bill to be introduced into Victorian Parliament legalising VAD [2]. ...
... On 25 May 1995, the Northern Territory in Australia made history by becoming the first jurisdiction in the world to legalise VAD [1]. The ROTTIA became law on 1 July 1996. ...
... The ROTTIA became law on 1 July 1996. This new law was promptly challenged in the Northern Territory Supreme Court (on 24 July 1996), where it was ruled as being valid legislation [1]. Not happy with this Supreme Court outcome, a Victorian Member of Parliament (MP), Kevin Andrews, introduced the Euthanasia Laws Bill 1996 into Federal Parliament in September 1996 [1]. ...
Article
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This paper provides a broad discussion about voluntary assisted dying (VAD) in Australia. The discussion examines the history of the VAD debate in Australia and whether public support for VAD and the arguments that have provided the framework for the VAD debate have evolved over time. This seems a prudent time to have such a discussion, given the very recent rush by all Australian states to bring about or attempt to bring about VAD legislation. This rush, inexplicably perhaps, comes after decades of attempted but failed progress in the legalisation of VAD in Australia. The authors attempted to undertake a systematic literature review for this paper, but the paucity of academic research and the lack of consistent terminology in this area made such a search untenable. Instead, the authors examined parliamentary documentation and then widened the search via the sources found within this documentation. The examination of available data showed that VAD has enjoyed significant public support from Australians over time and that the arguments in the VAD debate in Australia have been consistent over time.
... Sin embargo, la eutanasia es condenada por más profesionales de cuidados paliativos y las asociaciones médicas alrededor del mundo y es un delito en casi todos los países. En el norte de Australia, la eutanasia fue brevemente legalizado (Kissane, 1998) y en ciertas condiciones en Bélgica y los países bajos no es responsable a la pena. El suicidio asistido está permitido solamente en el estado de Oregon, Estados Unidos (Forbes, 2003). ...
... Debilidad y la depresión fueron las principales quejas. La mayoría de los pacientes solicitando la eutanasia era un loner (Kissane, 1998). Pensamientos de suicidio son más frecuentes en las personas que esperan el resultado de las pruebas para el VIH que aquellos que saben que son portadores del virus (Perry, 1990). ...
... Sin embargo, hay varios inconvenientes, uno de los cuales sería que el paciente puede ocultar deliberadamente sus síntomas depresivos de la contracción (porque se sabe que el psiquiatra podría invalidar su "elección" por la muerte). Otro problema sería cambiar la psiquiatra un juez que decida quien puede o no puede morir (Kissane, 1998). ...
Thesis
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El dolor crónico se considera un fenómeno complejo y subjetivo caracterizado por cambios plásticos en el sistema nociceptivo e hiperexcitabilidad del sistema nervioso central, así como alteraciones afectivas y cognitivas. El objetivo principal de esta tesis fue examinar los cambios cerebrales que se producen como consecuencia de la manipulación de diferentes factores afectivos, cognitivos y sociales, así como el papel de estos factores en el mantenimiento y exacerbación del dolor crónico. Asimismo, se pretendió caracterizar el funcionamiento intrínseco cerebral de los pacientes con dolor crónico durante el estado de reposo. Para alcanzar estos objetivos se llevaron a cabo seis estudios. Los dos primeros exploraron en sujetos sanos la actividad eléctrica cerebral en respuesta a la visualización de estímulos relacionados con dolor en otros
... In the Northern Territory of Australia, where euthanasia was enacted from 1996 to 1997 (via the Rights of the Terminally Ill Act 1995 (NT)), guidelines required a palliative care consultation before a patient's request for euthanasia could be considered (Kissane et al., 1998). This potentially posed a considerable challenge for any palliative care physician responding to such a request. ...
... If EAS were to be legalized, it could potentially reduce the palliative care physician's role to mere tokenism in order to satisfy a patient's request to address a formality. Other deficiencies of this legislative approach were highlighted by the limited assessment and management of depression in the Northern Territory cases cited above (Kissane et al., 1998). ...
Article
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Objective Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated—particularly around ethical and legal issues—and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community. Method We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized. Results We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered. Significance of Results Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.
... 20 No requests were denied by psychiatry; however, psychiatrists were seen as adversarial hurdles blocking successful endof-life care. 21 The Federal Parliament nullified the Act in 1997 and since then, PAS and euthanasia have been illegal in Australia. 21 According to the Supreme Court ruling, the person requesting PAD must be a "competent adult" who "clearly consents to the termination of life." 1 Two fundamental issues raised by these criteria are who should assess capacity and how capacity should be assessed. ...
... 21 The Federal Parliament nullified the Act in 1997 and since then, PAS and euthanasia have been illegal in Australia. 21 According to the Supreme Court ruling, the person requesting PAD must be a "competent adult" who "clearly consents to the termination of life." 1 Two fundamental issues raised by these criteria are who should assess capacity and how capacity should be assessed. Both issues have been debated in literature. ...
Article
On February 6, 2015, the Supreme Court of Canada ruled that the prohibition of physicianassisted death (PAD) was unconstitutional for a competent adult person who "clearly consents to the termination of life" and has a "grievous and irremediable (including an illness, disease, or disability) condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition."1 The radically subjective nature of this ruling raises important questions about who will be involved and how this practice might be regulated. This paper aims to stimulate discussion about psychiatry's role in this heretofore illegal practice and to explore how psychiatry might become involved in endof-life care in a meaningful, patient-centred way. First, I will review existing international legislation and professional regulatory standards regarding psychiatry and PAD. Second, I will discuss important challenges psychiatry might face regarding capacity assessment, the notion of rational suicide, and the assessment of suffering.
... Over recent years, there has been an increase in the legal availability and use of medical assistance in dying (MAID) around the world. Medical assistance in dying was first made legally available in the Australian state of Northern Territory in 1996 (Kissane et al., 1998), and is now legally obtainable in Belgium (Smets et al., 2010), Canada (Attaran, 2015), Colombia (Steck et al., 2013), Germany (Müller-Busch et al., 2004), Luxembourg (Steck et al., 2013), Netherlands (Rietjens et al., 2009), Switzerland (Bosshard et al., 2003), parts of Australia (Kissane et al., 1998), and some states in the United States (Quill et al., 2016). The subject of MAID also maintains a high profile in some other countries where specific cases have gained media attention, such as the fight by the terminally ill New Zealand woman Lecretia Seales to be able to legally end her own life (Jones, 2015;Nichol, 2015;Vickers, 2016;Lecretia's Choice, 2019). ...
... Over recent years, there has been an increase in the legal availability and use of medical assistance in dying (MAID) around the world. Medical assistance in dying was first made legally available in the Australian state of Northern Territory in 1996 (Kissane et al., 1998), and is now legally obtainable in Belgium (Smets et al., 2010), Canada (Attaran, 2015), Colombia (Steck et al., 2013), Germany (Müller-Busch et al., 2004), Luxembourg (Steck et al., 2013), Netherlands (Rietjens et al., 2009), Switzerland (Bosshard et al., 2003), parts of Australia (Kissane et al., 1998), and some states in the United States (Quill et al., 2016). The subject of MAID also maintains a high profile in some other countries where specific cases have gained media attention, such as the fight by the terminally ill New Zealand woman Lecretia Seales to be able to legally end her own life (Jones, 2015;Nichol, 2015;Vickers, 2016;Lecretia's Choice, 2019). ...
Article
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Around the world, the recent introduction of assisted death laws has meant that undertaking medical assistance in dying (MAID) is now an option for some persons wishing to end their life. Some of these people donate their bodies to medical science, and by doing so have created a new route from which donor programs can now receive bodies. Such donations have also illuminated a myriad of novel ethical questions. This article considers the emotive and controversial topic of MAID in relation to body donation, describing the experiences of McMaster University, Canada, where several MAID body donors have been received by the anatomical donor program. It provides background on the development and implementation of MAID in Canada, and describes the experience of staff and students at McMaster to MAID donations. It also explores the relevance of MAID to body donation programs, and discusses several of the ethical challenges facing body donation programs who may encounter MAID body donors. These include the appropriateness of accepting MAID donors, issues with informed consent, the effect of personal engagement with MAID donors, information sharing around MAID donations, governance issues, and negative historical parallels between MAID and euthanasia. Suggestions on how to manage MAID body donation focus on how issues affecting institutions, faculty, and students may be approached utilizing appropriate transparency and communication, some of which may facilitate student professional development around the topic of MAID. It is also suggested that the development of ethically appropriate guidelines on MAID body donations may positively guide the anatomical community. This article is protected by copyright. All rights reserved.
... [12][13][14][15][16] The doctor-patient interaction has additional significance where legislation permits assisted suicide, as specific roles are set for the doctor in assessing and responding to such a request. 11,17,18 In a previous report, 19 we investigated and described a set of patient factors associated with the wish to hasten death among 256 terminally ill patients. A discriminant function analysis revealed that the following eight variables measured among the patients predicted a high wish to hasten death (pϽ0.001): ...
Article
This study investigated the clinical factors associated with a wish to hasten death among patients with advanced cancer receiving palliative care, with a focus on the role of clinician-related factors. Patients were grouped into high-and low-scoring groups on the basis of their wish to hasten death; doctor-patient pairs were formed. Questionnaire data collected from patients and their treating doctors were subjected to multivariate analysis. Significant predictors of a high wish to hasten death in terminally ill patients from among treating clinicians included the clinician's perception of the patient's lower optimism and greater emotional suffering, the patient indicating a wish to hasten death, the doctor willing to assist the patient in hastening death (if requested and legal), and the doctor reporting less training in psychotherapy. When these variables were combined with patient factors identified in a previous study, the model significantly predicted a wish to hasten death with the following variables—patient factors: a higher perceived burden on others , higher depressive symptom scores, and lower family cohesion; physician factors: the doctor willing to assist the patient in hastening death (if requested and legal), the doctor's perception of lower levels of optimism and greater emotional distress in the patient, and the doctor having less training in psychotherapy; and the setting of care: recent admission to a hospice. The findings support the multifactorial influences on the wish to hasten death and suggest that the role of the clinician is a vital context within which the wish to hasten death should be considered.
... The Australian federal parliament overruled the Northern Territory law 9 months after it took effect. Just four people had died using the provisions of the law (Kissane Street, & Nitschke, 1998). The federal parliament's action was in the face of popular support for voluntary euthanasia, with opinion polls showing more than 75% of Australians in favor. ...
Article
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Proponents and opponents of euthanasia have argued passionately about whether it should be legalized. In Australia in the mid-1990s, following the world’s first legal euthanasia deaths, Dr. Philip Nitschke initiated a different approach: a search for do-it-yourself technological means of dying with dignity. The Australian government has opposed this effort, especially through heavy censorship. The citizen efforts led by Nitschke have the potential to move the euthanasia issue from a debate about legalization to a struggle over technology.
... Research has been undertaken to better understand the phenomenon of a WTD in terminally ill patients (literature overview in Appendix A). Earlier studies, mainly based on quantitative methods, reported a multifactorial etiology and an association between a WTD and depression and hopelessness [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. After 2000, some qualitative studies investigated the experience of dying patients with a WTD prospectively from a first-person perspective, confirming the multifactorial etiology [22][23][24][25][26][27][28][29]. ...
Article
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Objective To investigate the variations in and intentions of wishes to die (WTD) of palliative care cancer patients.Methods Thirty terminally ill cancer patients, their caregivers and relatives in a hospice, an oncology palliative care ward of a general hospital, and an outpatient palliative care service. 116 semistructured qualitative interviews analyzed by a combined approach using Grounded Theory and Interpretive Phenomenological Analysis.ResultsA WTD is dynamic and interactive. Its subjective phenomenology can be described by three aspects: intentions, motivations, and interactions. In this article, we present a typology of the possible intentions. We identified nine different (ideal) types of intentions that WTD statements might have, other than wishing to live and accepting death. Many WTD statements do not imply a desire to hasten death. The intentions of statements differ according to whether a WTD is related to as imaginary or as an action. Often WTD statements contain several partial wishes, which can be in tension with each other and form a dynamic, sometimes unstable equilibrium.Conclusions Terminally ill persons' WTD statements differ in their intention, and deeper knowledge about these differences is ethically relevant. © 2014 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.
... Others argue that for cancer patients receiving palliative care, the association between pain and suicidal ideation has not been demonstrated (Breitbart et al., 2000; Wilson et al., 2000). Of the seven patients who died in the Northern Territory when euthanasia was legal, all were cancer patients and none had uncontrolled pain (Kissane, Street, & Nitschke, 1998). Pain intensity may contribute to predicting a desire for death (Rosenfeld, Krivo, Breitbart, & Chochinov, 2000). ...
Article
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For the clinician who works in a palliative health care setting, the suicidal ideation of palliative care patients is a challenge. How are patients with a life-limiting illness who wish to hasten their death, and who express this suicidal ideation, understood in the context of Palliative Care? The present article is a systematic literature review of published research to determine how this issue has been addressed in palliative care and the implications for social work practice. Because suicidal ideation and depression tend to be undertreated in the medically ill, the article examines whether there may, indeed, be barriers in the psychosocial environment of care for palliative patients. Attention was paid to determine how suicidal ideation has been variously interpreted and whether it has been linked to hopelessness. Of the relevant studies, which were primarily from leading services in the field, there is little evidence of approaches to suicidal ideation in palliative care to improve mental health outcomes for patients.
... In Australia, EAS was only legal in the Northern Territory between July 1996 and May 1997. Under the Act, seven terminally ill cancer patients requested physician-assisted suicide; of those, four people died (Kissane et al, 1998). Since the repeal of the Act in 1997, EAS is illegal in Australia. ...
Article
IntroductionAn increasing demand for physicians’ involvement in life-ending decisions has led to extensive debate on euthanasia and right-to-die issues by social, political and medical groups. The Commonwealth Department of Health and Aged Care commissioned an evaluation of the need to educate undergraduate medical students on suicide prevention, euthanasia and life-ending issues.Methods Semi-structured interviews were conducted on samples of medical school coordinators, medical students and general practitioners (GPs). Key academics in Curriculum and/or Accreditation Committees from 10 of 15 Australian Medical Schools (AMS) participated in a survey on the possible implementation of suicide prevention, euthanasia and life-ending issues in undergraduate courses. Medical students (n = 373) were asked to rate their attitude toward the same issues. Twenty-four GPs from six different states (rural/urban environments) were asked to rate the level of importance of a specific curriculum on suicide prevention, euthanasia and life-ending issues.ResultsMedical students showed high interest in learning about euthanasia and life-ending issues (76.8%), quality of life and quality of death (85.1%), and different types of euthanasia and physician-assisted suicide (70%). They reported that physicians should be involved in ending-life decisions (89%). Forty per cent of AMS thought education on euthanasia and life-ending issues was essential. Fifty-four per cent of GPs considered education in euthanasia and related issues a high priority.DiscussionThe increasing aging population and the high prevalence of chronic illness call for a growing involvement of physicians in this difficult area of medical practice. Globally, the need for undergraduate education on these matters is perceived as important and urgent.
... In the case of Genetic engineering, the responsibility ethics began probably with the agreements of Asilomar, in 1972, distinguishing between the "negative" and the "positive", and also the "somatic" and the "germ line" genetic engineering (19). Genetic engineering made in somatic cells with the intention of correcting or curing diseases (negative genetic engineering) is today considered as responsible and prudent; but there is a great debate about the convenience of changing germ line cells with this same goal, and it is generally rejected as imprudent the manipulation of either somatic or germ line cells in order to enhance the human nature. ...
... 3 [31]. The Northern Territory of Australia also legalised voluntary euthanasia and assisted suicide in 1996, but the Federal government overrode the legislation in 1997 [32]. In the UK, a woman with motor neuron disease applied to the British court in 2000 for a guarantee that if her husband helped her to commit suicide, he would not legally be prosecuted [33]. ...
Article
This paper has two aims, to summarise recent domestic and international events related to medicoethical-legal decisions in the clinical setting and to discuss the ethical implications of these events. Domestic issues include brain death and organ transplantation, refusal of treatment for religious reasons, disclosure required for legitimate informed consent, surrogate motherhood, prenatal diagnosis and selective abortion, issues pertaining to HIV/AIDS, concealment of medical mistakes, truth telling, public trust in physicians and in health care, and medical research. International issues include voluntary euthanasia and assisted suicide, the imposed separation of conjoined twins, problems pertaining to wrongful life, fetal surgery, the Icelandic database, homosexuality, resource allocation and global justice, and the death of participants in medical research. It is hoped that this review of recent events related to clinical ethics may serve as a basis for ethical considerations in daily practice.
... These data are comparable to the data from the Netherlands, in which 80% of euthanasia and 78% of PAS cases involved patients with cancer, 66 and from the Northern Territory, Australia, where all 7 patients who received euthanasia when it was briefly legalized had cancer. 67 Second, it appears that pain is not a major determinant of interest in or use of euthanasia or PAS (Table 5). Almost all of these studies-as well as the interviews with physicians who have administered euthanasia and PAS 34,43 -have shown that pain is not a predictor of patients' interest in euthanasia or PAS. ...
Article
For more than a decade, there has been an intense debate about the ethics and legality of euthanasia and physician-assisted suicide (PAS) in the United States. 1-5 In June 1997, the US Supreme Court unanimously ruled that there is neither a constitutional right nor a constitutional prohibition to euthanasia or PAS. 6,7 This permitted Oregon to experiment with legalizing PAS. During this decade, most other states have consistently opposed legalization. In the weeks after the US Supreme Court decision, the Florida Supreme Court also ruled that there is no constitutional right to PAS. 8 At least 7 state legislatures have voted to explicitly prohibit euthanasia and PAS. 9 Indeed, a bill to legalize euthanasia or PAS has been considered by a full chamber of a state legislature in only one state, Maine, and that bill was defeated 99 to 42. 10 In November 1998, 70% of the voters of Michigan resoundingly defeated a referendum to legalize PAS, while in November 2000 Maine voters also rejected legalizing PAS. 11
... Moreover, terminally ill patients may feel stigmatized by being mandated to undergo a psychiatric examination. In Australia, Kissane et al. 29 found that mandated psychiatric assessments for patients requesting euthanasia or PAS sometimes leads them to withhold key information because they see the psychiatric assessment as a legal hurdle to be overcome, suggesting also that mandated psychiatric assessments may compromise the relationship between psychiatrist and patient. ...
Article
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Physician-assisted suicide (PAS) is one of the most provocative topics facing society today. Given the great responsibility conferred on physicians by recent laws allowing PAS, a careful examination of this subject is warranted by psychiatrists and other specialists who may be consulted during a patient's request for PAS. In this article, recent evidence regarding the implementation of PAS in the United States and The Netherlands is reviewed. Support is found for some concerns about PAS, such as the possibility that mental illness occurs at higher rates in patients requesting PAS, but not for other concerns, such as the fear that PAS will be practiced more frequently on vulnerable populations (the slippery-slope argument). These data and common arguments for and against PAS are discussed with an emphasis on the tension between values, such as maximizing patient autonomy and adhering to professional obligations, as well as the need for additional research that focuses more directly on the patient-centered perspective. Implications of the available evidence are discussed and lead to a consideration of mental anguish in terminally ill patients including aspects of existential distress and an acknowledgment of the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. The article concludes with a discussion of an expanding role for psychiatrists in evaluating patients who request PAS. © 2015 American Academy of Psychiatry and the Law.
... Empirische Studien aus den Niederlanden, Oregon und Northern Territory geben hier ein erstes und deutliches Signal: Es zeigt sich, dass die zu ertragenden Schmerzen bei den Patienten, die um ihre Tötung bitten, de facto nicht zu den wichtigsten Motiven oder Beweggründen zählen. Vielmehr werden die Angst vor Verlust der Selbständigkeit, der Abhängigkeit von anderen und depressive Verstimmungen als Beweggründe genannt, auch die Angst vor unerträglichen Schmerzen ( [4,17,23,24,26]). Offensichtlich geht es den betroffenen Patienten weniger um die Vermeidung unerträglicher Schmerzen als vielmehr um das Verhindern einer Lebensphase der Abhängigkeit von der Hilfe anderer Menschen. ...
Article
Definition of the problem: In parallel with public and philosophical discussions, there is an ongoing debate about euthanasia in theological ethics. In this situation it is helpful to provide a systematic overview of the different arguments and judgements. Arguments: A short introduction is followed by a first part dealing with the definition of terms. The second and major part concerning normative arguments is subdivided into three steps: the level of principles, the more concrete level of actions and finally the level of social consequences. The third part presents some reflections following the eudaimonistic ethical tradition (the ethics of a good life and death) focusing on the central question: how to find meaning in life when faced with suffering. Conclusion: It would be fruitful to intensify the ethical reflection both on the problems concerning the foundations of social life, especially the meaning of dignity, autonomy and inviolability of human life, and social consequences of a liberal practice of euthanasia. In this context ethicists are challenged to reflect on the different approaches to what is or can be a good life and a human death.
... Christian opposition to the possibility of legalisation in different countries have shared some similar characteristics (Gandsman 2016). In (Kissane, Street and Nitschke 1998;Plattner 1997). The Victorian Parliament traversed a similar topic in the late 1980s but concluded that at the time 'it is neither desirable or practicable for any legislative action to be taken establishing a right to die' (Victoria. ...
Article
Assisted dying is a topic fraught with theological and ethical contention. It has been regularly debated in Australian parliaments and is currently under active consideration in New South Wales and Victoria. The Victorian process involved a public inquiry by a committee of Victoria’s upper house which attracted more than a thousand submissions. This paper analyses the submissions made to that committee by Christian churches and organi- sations with a Christian affiliation. All bar one of the submissions were opposed to legalising assisted dying. The two most common themes in the Christian submissions were the need to expand palliative care services and that adequate palliative care could be an alternative to assisted dying; and that even narrowly constrained legalising of assisted dying could lead to a slippery slope with further expansions and potential harm to vulnerable populations. These arguments were not successful and the committee supported legalising assisted dying. Possible reasons for the failure of the Christian arguments are explored.
... 7 The Northern Territory's Act was repealed by Australia's federal government less than one year after enactment, due to political and ideological differences between the federal and Northern Territory governments at that time. 8 Most recently, Western Australia's (WA) State Parliament passed a Voluntary Assisted Dying Bill into law on December 10, 2019. 9 Similar to Victoria, there is an 18 month implementation period led by the WA Department of Health, making WA the second Australian state to legalize assisted dying. ...
Article
Background Worldwide, pharmacy practice is changing to include new roles and responsibilities. Laws enabling the implementation of assisted dying are expanding in international jurisdictions. Pharmacy practice in assisted dying is subsequently expanding. However, studies of how pharmacists experience their practice when engaged in assisted dying are absent. To progress research into the lived experiences of pharmacists practicing in assisted dying, the development of an inquiry framework to guide such research is the first step. Objective The objective was to develop a theoretical framework of inquiry for use in subsequent continuing research which may explore the actual experience of pharmacy practice in assisted dying. Methods Perspectives were gathered from expert and senior pharmacists who were anticipating the imminent implementation of assisted dying practice. Analysis centred on understanding what aspects of practice experience were important to them. Interview-conversations centred on the question: If you had the chance to talk to experienced pharmacist practitioners who have been involved in the practice of assisted dying, what aspects regarding their experiences, would you like to know about? A conventional approach to qualitative content analysis was utilized to analyze the data. Results Findings summarized questions posed by pharmacists contemplating the implementation of assisted dying practice. These perspectives formed the foundation of a theoretical inquiry framework constituted by 8 inter-related dimensional range-continuums. Each range-continuum, designed to explore the lived experiences of pharmacists in practice, is defined. Examples of how the inquiry dimensions will be used to inform future exploratory research are offered within the framework. Conclusions The theoretical inquiry framework will be used to develop knowledge for pharmacists contemplating participation (or not) in assisted dying practice. It is timely to progress research that reveals the informed experiences of pharmacists that are actually practising in this area. The framework may be adapted for researching pharmacists’ experience in other practice areas and contexts.
... Reverend Ralph Mero, a Unitarian Universalist minister, is the co-founder of Compassion in Dying, an organization dedicated "to helping terminally ill patients end their lives" and legalizing assisted suicide (Belkin, 1993, p. 50). Dr. Philip Nitschke is the physician who administered euthanasia to seven persons in the Northern Territory of Australia (four persons died under Northern Territory Act and three more around same time) (Kissane, Street, & Nitschke, 1998). In the Netherlands, Dr. Pieter Admiraal is one of the leading Dutch pro-euthanasia doctors. ...
Chapter
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Feminist perspectives have enriched our understanding of violence against women, especially of issues such as sexual harassment, rape, and battering. Feminist perspectives, however, are less commonly applied to issues of violence that are more unique to older women. In this chapter I review and discuss, according to a feminist perspective, findings from studies of so called mercy killing. Mercy killing is usually defined as intentional killing, often by family members or friends, with the stated intent to end perceived suffering.
... Between the passage of the Northern Territory legislation and the enactment of the Commonwealth legislation overturning it, seven people applied for assistance in dying under the Northern Territory legislation's provisions (Kissane et al. 1998). All had cancer, two died before the Act came into effect, and one died after its repeal. ...
Article
Public opinion polling shows that Australians have long supported legalising assisted dying, but this has not generally led to legislative success. Since 1993, Australian parliament have considered legalising assisted dying over 50 times, with only two attempts being successful: Northern Territory in 1995 and Victoria in 2017. This paper describes the Northern Territory and Victorian legislation and the processes associated with the passage of the legislation in both jurisdictions. It suggests that one of the factors that contributed to the Victorian outcome was the extensive consultation involved prior to the introduction of the legislation into parliament. Political factors – including government support – also facilitated the legislation's passage.
Article
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This article is concerned with the practice of euthanasia in Belgium. Background information is provided; then major developments that have taken place since the enactment of the Belgian Act on Euthanasia are analysed. Concerns are raised about (1) the changing role of physicians and imposition on nurses to perform euthanasia; (2) the physicians' confusion and lack of understanding of the Act on Euthanasia; (3) inadequate consultation with an independent expert; (4) lack of notification of euthanasia cases, and (5) organ transplantations of euthanized patients. Some suggestions designed to improve the situation and prevent abuse are offered.
Article
Die öffentliche Diskussion um die Betreuung Sterbender am Lebensende wird von zwei zentralen Themen bestimmt: 1. Welchen Stellenwert haben im Voraus in Patientenverfügungen (PV) festgelegte Wünsche im Hinblick auf Therapieentscheidungen am Lebensende und 2. wie soll dem speziellen Wunsch nach einem vorzeitigen Tod im Sinne einer aktiven Sterbehilfe Rechnung getragen werden? Eine von der Deutschen Forschungsgemeinschaft geförderte multizentrische Studie (FKZ: RA 1697/1-1; NA 780/1-1; VO497/4-1) wird diesen gesellschaftspolitisch hochrelevanten Fragen mit multimethodischen Ansätzen (Mixed Methodology) nachgehen. In Aachen besteht das Arbeitspaket darin zu erforschen, was der implizite Auftrag an die Ärzte ist, wenn Patienten den Wunsch nach aktiver Sterbehilfe äußern. In Bonn (in Zusammenarbeit mit Göttingen) sollen die Inhalte von Patientenverfügungen mit den Erwartungen der Verfasser (Patientengruppen und Kontrollgruppe von Gesunden) in Bezug auf ihre Versorgung am Lebensende verglichen werden. In Köln wird die Praktikabilität und Validität eines Screenings mit einem standardisierten Fragebogen zur frühzeitigen und differenzierten Erkennung des Sterbewunsches beforscht. Die Kooperation der palliativmedizinischen Lehrstühle an den Universitäten Aachen, Bonn (zusammen mit Göttingen) ist einzigartig. Dieses „ABC-Dreieck” ist nicht nur historisch der Beginn der Palliativmedizin in Deutschland (1983 Gründung der ersten Palliativstation in Köln, 1986 Gründung des ersten stationären Hospizes in Aachen, 1999 Besetzung des ersten Lehrstuhls für Palliativmedizin in Bonn), sondern bietet hervorragende infrastrukturelle Voraussetzungen zur Erforschung dieser Themen. So können die einzelnen Palliativstationen durch ihre enge Nachbarschaft zueinander ausreichende Patientenzahlen für Forschungsvorhaben erreichen und damit die Erfolgsaussichten der geplanten Untersuchungen erhöhen. Die eingebundenen Forscher können für ihre Untersuchungen auf ethisch anspruchsvollen Gebieten die Ressourcen und Synergien des „ABC-Dreiecks” nutzen. Durch die enge Kooperation der Arbeitsgruppen, in die weitere Experten aus anderen Fakultäten eingebunden sind, stehen hohe medizinische, psychologische, soziologische, ethische, juristische und theologische Kompetenz für die Entwicklung und Durchführung der Methodik zur Verfügung. Wir hoffen, dass wir mit diesem Verbundforschungsprojekt eine anhaltende Entwicklung der palliativmedizinischen Forschung und hochrangigen Forschungsförderung in Deutschland anstoßen können!
Article
Background: An increasing number of jurisdictions around the world are legalizing assisted dying. This creates a particular challenge for the field of palliative care, which often precludes producing premature death by the injection or self-administration of lethal medications upon a patient's voluntary request. A 2019 systematic scoping review of the literature about the relationship between palliative care and assisted dying in contexts where assisted dying is lawful, found just 16 relevant studies that included varied and combined stances ranging from complete opposition, to collaboration and integration. Building on that review, the present study was conducted in Quebec (Canada), Flanders (Belgium), and Oregon (USA), with the objective of exploring the relationship between palliative care and assisted dying in these settings, from the perspective of clinicians and other professionals involved in the practice. Methods: Semi-structured in-depth qualitative interviews were conducted with 29 professionals from Oregon [10], Quebec [9] and Flanders [10]. Participants were involved in the development of policy, management, or delivery of end of life care services in each of the jurisdictions. Data was analyzed thematically and followed a procedure of data immersion, and the construction of a thematic and interpretive account. Results: Three themes were identified from each of the locations. Flanders: the integrated approach; discontents in palliative care; concerns about liberalization of assisted dying laws. Oregon: the role of hospice; non-standardized protocols and policies; concerns about access to medications and care. Quebec: a contested relationship; the special situation of independent hospice; lack of knowledge about and access to palliative care. Conclusions: No clear and uniform relationship between palliative care and assisted dying can be identified in any of the three locations. The context and practicalities of how assisted dying is being implemented alongside access to palliative care need to be considered to inform future laws. We seek a better understanding of whether and in what ways assisted dying presents a threat to palliative care.
Article
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Aims and method To explore the views of Egyptian psychiatrists on physician-assisted suicide, focusing on demographical, spiritual, legal and clinical domains. We surveyed the views of psychiatrists in four Egyptian counties using a structured questionnaire with a five-point Likert response scale. Results A total of 160 psychiatrists completed the questionnaire (response rate 82%). Of these, 50% described the influence of their religious beliefs on their medical practice as very strong/strong and 12.5% as weak/nil. The majority (75%) said they would disagree or strongly disagree with supporting physician-assisted suicide for a terminally ill patient; a similar proportion (76%) were against passive euthanasia. The majority (77%) felt that physician-assisted suicide was against their religious beliefs; there was no significant difference between Muslims and Christians. The majority (82.4%) believed that physician-assisted suicide could/will be abused. Clinical implications Careful consideration should be given to the safeguarding of psychiatric patients if physician-assisted suicide is legalised. Future studies on the views of clinicians should explore the influence of cultural differences rather than religious beliefs.
Article
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.
Article
Aim: To explore whether public support for and opposition to Euthanasia and Physician Assisted Suicide (EPAS) as measured in historic Australian and New Zealand polls has been influenced by the wording of survey questions. Methods: Australian and New Zealand random-sample post-1995 EPAS poll questions asked of the general public were identified and subjected to content analysis. Individual phrases and words were considered in terms of their favourability towards or unfavourability against EPAS and each poll question was assigned a net favourability score. Variation of support for EPAS based on year, location and favourability of language was analysed by various statistical methods. Results: Mean public support for EPAS in Australia and New Zealand between 1995 and the present was 70.2% with support ranging between 47% and 85%. Support did not vary by location and has remained unchanged over time. However, support was positively associated with increasing levels of favourable wording, accounting for over 20% variation in mean support. Allusions to hopelessness had an especially strong effect on increasing support for EPAS. Conclusion: Use of emotive phrases and language is associated with influencing attitudes to EPAS in Australia and New Zealand. Therefore, caution should be exercised when interpreting public support for EPAS based on individual polls. This article is protected by copyright. All rights reserved.
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This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the person onto “oblivion”.
Article
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Part of the reason for the ongoing confusion regarding the status of assisted suicide is the cluttered moral and legal matrix that is normally invoked to evaluate the practice. It results in a calculus that is impossible to coherently unravel, allowing commentators to tenably assert any position. The authors attempt to inject clarity into the debate by focusing on the issue through the lens of the most important interest at stake: the right to life. It is arguable that while there are well-established exceptions to the right to life, they only apply where the right to life is itself at stake (such as self-defence). There is no sound argument for suggesting that the circumstances underpinning suicide constitute another exception to the right to life. Thus, suicide and assisted suicide are unjustifiable. An analysis of the empirical data in jurisdictions where assisted suicide has been legalised suggests that legalisation leads to an increase in assisted suicides. The adverse indirect consequences of the often ostensibly compassionate act of assisted suicide outweigh any supposed benefits from the practice. It follows that assisted suicide should lead to criminal sanctions. At the same time, it is important to acknowledge that, paradoxically, the right to life arguments against assisted suicide mandate greater community measures to eliminate or reduce the causes of suicide.
Article
The increasing availability of physician assisted death has opened up a novel means of making donated bodies available for anatomical dissection. This practice has come to the fore in Canada, but is unlikely to be confined to that country as legislation changes in other countries. The ethical considerations raised by this development are placed within the framework of the ethical guidelines on body donation promulgated by the International Federation of Associations of Anatomy (IFAA). The discussion centers on understanding the ethical dimensions of moral complicity, and whether it is accepted or rejected. If rejected it is possible to separate ethical concerns regarding physician assisted death from subsequent use of donated bodies, as long as there is fully informed consent and complete ethical and procedural separation of the two. Openness about the origin of bodies for dissection is essential. Students should be instructed on the nuances of moral complicity, and consideration be given to those with moral doubts about physician assisted death. Two issues are raised in considering whether these moves represent an ethical slippery slope: the attraction represented by obtaining relatively ‘high quality’ bodies, and the manner in which organ donation following physician assisted death has led to challenges to the dead donor rule. Although body donation raises fewer concerns, the ethical dimensions of the two are similar. The ethical constraints outlined here have the capacity to prevent an ethical slippery slope and constitute a sound basis for addressing an innovative opportunity for anatomists.
Article
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Suicide, assisted suicide and euthanasia are elusive and controversial issues worldwide. To discuss such issues from only one perspective may be limiting. Therefore, this paper was written by authors from various regions, each of whom has been asked to reflect on the issues. The countries/cultures are: Australia, China, Cuba, Ireland, India, Japan, Russia, South Africa, The Netherlands, North America (Turtle Island) and United States. Historically and today, suicide is viewed differently. Assisted suicide and euthanasia are equally seen from multifarious perspectives. Highlighting development in the Netherlands, Australia's Northern Territory and Japan (ie. the famous Yamanouchi Case), the review shows growing re-examination of the right to die. There appear, however, to be no uniform legal and ethical positions. Further debate and discussion globally is needed to avoid myopic perspectives.
Article
Importance: The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices. Objective: To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices. Evidence review: Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016. Findings: Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population. Conclusions and relevance: Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.
Chapter
In an interesting and provocative article, Professor Tännsjö has suggested that terminal sedation at the patient’s request might function as an alternative to voluntary euthanasia and resolve the deadlock between those who support voluntary euthanasia, and those who oppose it on the grounds that it infringes the Sanctity-of-Life Doctrine1. I disagree. While terminal sedation would be an acceptable alternative to some supporters of voluntary euthanasia, it would be opposed by traditional supporters of the Sanctityof-Life Doctrine. As I shall attempt to show, terminal sedation involves the intentional termination of life or killing and would thus constitute euthanasia. Substantially, I shall argue that the Sanctity-of-Life Doctrine, in its reliance on the Doctrine of Double Effect, is not an appropriate basis for clinical decisionmaking and the law. In the absence of convincing reasons to the contrary, doctors should be allowed to provide both terminal sedation and euthanasia to terminally or incurably ill patients, at the patients’ request.
Chapter
Ethical frameworks inform the use of psychopharmacological and biological treatment in psycho-oncology. In this chapter we examine ethical aspects of informed consent psychopharmacology, off-label, unproven and “alternative” therapies, pharmacological trials, and the placebo effect. We consider the relationship between the practitioner and the pharmaceutical industry, how to ethically integrate psychotherapy with pharmacotherapy, and common pitfalls in this regard. We describe how to prescribe well and, in this regard examine the challenges of delirium, terminal delirium, terminal sedation, physician assisted suicide and euthanasia. Finally, we review the ethically and clinically challenging subjects of addiction to prescribed medications and transcranial magnetic stimulation.
Chapter
There can be few more volatile policy debates than that of aging and euthanasia. If AIDS has come to be seen as the disease that “most justifies” the right to die (Magnusson 2002, 49), then old age must surely be one of the most difficult contexts in which to consider a policy of assisted death. Apart from the usual arguments about personal choice, pain and suffering, and compassion, versus arguments about palliative care, the role of medicine and the “slippery slope” (Miller 1996), looms the troubling issue of health care rationing (Callahan 1996). As the costs of chronic and end-of-life care continue to rise, some fear that even a well-intentioned policy permitting voluntary assisted death would become corrupted (Santamaria 1996). Depression and dementia, where evident in later life, further complicate the policy equation. Tobin predicts that doctors would become emboldened “to act on ascribed ‘autonomous wishes’, that is to say, on ‘what the patient would have wanted if only he [or she] were able to tell us”’ (Tobin 1995). Together, these factors generate a bleak (albeit imagined) scenario: one where death in old age becomes a subtly “persuaded act,” a choice disproportionately made by the vulnerable and self-effacing, those wishing to conserve the family silver and to spare loved ones the agony of waiting.
Article
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The development and elaboration of a conceptualization of existential distress in patients with advanced disease is crucial in order to optimize our clinical response within palliative medicine. Demoralization is one expression of existential distress. Its empirical study will be greatly enhanced by a self-report measure that captures its dimensions and intensity. We report here on the development and testing of the Demoralization Scale in 100 patients with cancer. Factor analysis identified five relatively distinct dimensions: loss of meaning, dysphoria, disheartenment, helplessness, and sense of failure. These factors show high internal reliability, and convergent validity with the McGill Quality of Life Scale, Patient Health Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, Hunter Opinions and Personal Expectations Scale, and the Schedule of Attitudes toward Hastened Death. Its divergent validity is demonstrated through the differentiation of a subgroup of patients with high demoralization who do not meet DSM-IV categorization for a diagnosis of major depression. Confirmatory validation is needed for the scale to be used as a measure of change in interventions designed to treat demoralization.
Book
Cambridge Core - Medico-Legal, Bioethics and Health Law - Euthanasia, Ethics and Public Policy - by John Keown
Article
The question whether assisted dying (euthanasia and assisted suicide) should be legalized is often treated, by judges and commentators alike, as a question which transcends national boundaries and diverse legal systems. One obvious example is the use made of the 'Dutch experience' in other jurisdictions. By treating the issue as a transcendent, global ethical question, the important context in which individual jurisdictions make decisions about assisted dying and the significance of the legal methods chosen to carry out those decisions is often lost. This book concentrates not on the issue of whether assisted dying should be legalized, but rather on the impact of the choice of a particular legal route towards legalization. Legal change on assisted dying may be achieved in a variety of ways: challenges to criminal prohibitions using constitutionally entrenched rights; the use of defences available to defendants who are prosecuted for assisting a death; legislative change; or referenda or ballot measures proposed by individual citizens or interest groups. The examination in this book of the impact of these different alternatives suggests that greater caution is needed before relying on the experience of one jurisdiction when discussing proposals for regulation of assisted dying in others, and the possible consequences of such regulation. The book seeks to demonstrate the need to explore the legal environment in which assisted dying is performed or proposed in order to evaluate the relevance of a particular legal experience to other jurisdictions.
Chapter
Die (straf-)rechtlichen Grenzen im Umgang mit dem menschlichen Körper werden anhand heute aktueller Bereiche diskutiert, wie z. B. Rettungsfolter, Zwangssterilisation, Knabenbeschneidung, Sterbehilfe, Organtransplantation, sexuelle Belästigung, Pornografie, Bildnis- und Datenschutz. Als Tendenz zeigt sich, dass dem Schutz des menschlichen Körpers in der Rechtsordnung eine zunehmende Bedeutung beigemessen wird, gleichzeitig aber auch der autonomen Entscheidung über den eigenen Körper eine höhere Bedeutung zukommt als früher. Der Gedanke der Pietät i. S. einer Ehrfurcht vor dem menschlichen Körper, wird hingegen i. d. R. nicht mehr als ausreichend angesehen, um ein rechtliches Verbot zu begründen.
Article
Bioethical issues can be classified into six different types. Each of these types of issues raises many specific questions that can be subjected to research. During the past 35 years, there has been a significant increase in interest in bioethical questions. These questions are not merely matters of opinion or feelings. They are bioethical questions that require rigorous research. And like other types of clinical research, research into bioethical issues utilizes a variety of methodologies that should adhere to the same standards of rigor. However, there are some special considerations that relate to bioethical research. First, some of the methods used are not well known to clinical researchers and are not the ones in which they have been trained. Second, clinical researchers may perceive some of the distinctions made in conceptual analysis as difficult. This chapter reviews different types of bioethical issues, different types of research methodologies, examples of how these research methodologies have been utilized to answer important bioethical questions, and special considerations in bioethical research. There are five main bioethical research methodologies: historical inquiry, conceptual analysis, crosscultural comparisons, empirical studies, and policy analysis.
Article
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Euthanasia and physician-assisted suicide have become prominent medical and social issues. This study investigated the prevalence of the desire for death in terminally ill patients, the stability of this desire over time, and its association with psychiatric disorders. Two hundred terminally ill inpatients were given semistructured interviews that assessed their desire for death and evaluated them for major and minor depressive episodes according to the Research Diagnostic Criteria. Each patient also completed a short form of the Beck Depression Inventory and provided ratings of pain and social support. When possible, patients who expressed a desire for death received a follow-up interview after a 2-week interval. Although occasional wishes that death would come soon were common (reported by 44.5% of the patients), only 17 (8.5%) of these individuals acknowledged a serious and pervasive desire to die. The desire for death was correlated with ratings of pain and low family support but most significantly with measures of depression. The prevalence of diagnosed depressive syndromes was 58.8% among patients with a desire to die and 7.7% among patients without such a desire. Follow-up interviews were conducted with six patients; in four cases, the desire to die had decreased during the 2-week interval. The desire for death in terminally ill patients is closely associated with clinical depression--a potentially treatable condition--and can also decrease over time. Informed debate about euthanasia should recognize the importance of psychiatric considerations, as well as the inherent transience of many patients' expressed desire to die.
Article
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In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.
Article
One hundred patients with cancer were interviewed regarding their attitude to a range of final life events in both their current real and hypothetical future circumstances. Patients who anticipated a future possible role for the more passive options of wishing death to come early or ceasing all treatment, were more hopeless and had a reduced quality of life. Patients however who anticipated a role for the more active options of suicide and/or euthanasia were less fatalistic and did not report a reduced quality of life. The desire for suicide was particularly positively related to younger age, a personal psychiatric past history, and a number of treatment-related variables reflecting increased patient autonomy.
Article
One hundred oncology patients from a major teaching hospital were asked about their attitudes to a number of final life events including active withdrawal from treatment, the refusal of cardiopulmonary resuscitation, suicide and euthanasia. A descriptive approach was used incorporating semi-structured interviews and established questionnaire measures. One third of the patient sample anticipated some role for taking active steps to end their own lives. This was not restricted to those currently psychologically disturbed nor to any particular demographic subgroup. Patients with more severe illness or poor prognosis did not express interest in suicide and euthanasia. A positive past psychiatric history increased the potential for seeing suicide as an option. The results have significant implications for the establishment of patient care protocols in final life events.
Article
Among 44 terminally ill patients, the majority (N = 34) had never wished death to come early. Of the remainder, three were or had been suicidal and seven more had desired early death. All 10 patients who had desired death were found to be suffering from clinical depressive illness. The methodologic difficulties encountered by the authors were the lack of a brief, efficient interview schedule suitable for debilitated patients and criteria for depressive disorder that do not depend on suicidal thoughts or on symptoms that can also be caused by physical disease.
Article
This study surveyed HIV-infected patients' attitudes toward physician-assisted suicide and examined the relationship between interest in physician-assisted suicide and physical and psychosocial variables. Three hundred seventy-eight ambulatory HIV-infected patients, 90% of whom met the criteria of the Centers for Disease Control for AIDS, were recruited from several sites in New York City. Self-report measures were used to assess pain, physical symptoms, psychological distress, depression, and social supports. Attitudes toward, and interest in, physician-assisted suicide were assessed through responses to a questionnaire. Sixty-three percent of the patients supported policies favoring physician-assisted suicide, and 55% acknowledged considering physician-assisted suicide as an option for themselves. The strongest predictors of interest in physician-assisted suicide were high scores on measures of psychological distress (depression, hopelessness, suicidal ideation, overall psychological distress) and experience with terminal illness in a family member or friend. Other strong predictors were Caucasian race, infrequent or no attendance at religious services, and perceived low level of social supports. Interest in physician-assisted suicide was not related to severity of pain, pain-related functional impairment, physical symptoms, or extent of HIV disease. HIV-infected patients supported policies favoring physician-assisted suicide at rates comparable to those in the general public. Patients' interest in physician-assisted suicide appeared to be more a function of psychological distress and social factors than physical factors. These findings highlight the importance of psychiatric and psychosocial assessment and intervention in the care of patients who express interest in or request physician-assisted suicide.
Article
Euthanasia and physician-assisted suicide are pressing public issues. We aimed to collect empirical data on these controversial interventions, particularly on the attitudes and experiences of oncology patients. We interviewed, by telephone with vignette-style questions, 155 oncology patients, 355 oncologists, and 193 members of the public to assess their attitudes and experiences in relation to euthanasia and physician-assisted suicide. About two thirds of oncology patients and the public found euthanasia and physician-assisted suicide acceptable for patients with unremitting pain. Oncology patients and the public found euthanasia and physician-assisted suicide least acceptable in vignettes involving "burden on the family" and "life viewed as meaningless". In no vignette--even for patients with unremitting pain--did a majority of oncologists find euthanasia or physician-assisted suicide ethically acceptable. Patients actually experiencing pain were more likely to find euthanasia or physician-assisted suicide unacceptable. More than a quarter of oncology patients had seriously thought about euthanasia or physician-assisted suicide and nearly 12 percent had seriously discussed these interventions with physicians or others. Patients with depression and psychological distress were significantly more likely to have seriously discussed euthanasia, hoarded drugs, or read Final Exit. More than half of oncologists had received requests for euthanasia or physician-assisted suicide. Nearly one in seven oncologists had carried out euthanasia or physician-assisted suicide. Euthanasia and physician-assisted suicide are important issues in the care of terminally ill patients and while oncology patients experiencing pain are unlikely to desire these interventions patients with depression are more likely to request assistance in committing suicide. Patients who request such an intervention should be evaluated and, where appropriate, treated for depression before euthanasia can be discussed seriously.
Article
After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide. An anonymous questionnaire was sent to all 418 Oregon psychiatrists. Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide. Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low.
Article
To examine the effect of improvement or recovery from major depression in elderly patients on their desire for life-sustaining treatments. Prospective case survey. Psychogeriatric Service of Hornsby Ku-ring-gai Hospital & Community Health Services and Ryde Hospital & Community Health Services (a community-based service serving an urban population with over 29,000 elderly people). All patients referred with major depression (diagnosed by DSM-IV criteria) and no significant cognitive impairment between October 1994 and January 1995. Number of life-sustaining treatments desired before and after treatment of depression in two hypothetical acute life-threatening illnesses (one with a good and the other with an uncertain prognosis), and intensity of depression on the Geriatric Depression Scale (GDS). 22 subjects completed both stages of the study. Initial depression was severe in five, moderate in 16 and mild in one. GDS scores decreased in 18 subjects after treatment. Mean number of life-sustaining treatments desired by these patients increased significantly from 4.0 to 6.1 (out of seven possible treatments) in the "good prognosis" illness and from 6.4 to to 9.6 (out of 14) overall. The increase in the "uncertain prognosis" illness (2.3 to 3.4) was not significant. Moderate or severe major depression in the elderly is associated with a high degree of refusal of life-sustaining treatments. Treatment of the depression leads to increased acceptance of these treatments, particularly if prognosis is good.
Article
In the Netherlands, a notification procedure for physician-assisted death has been in use since 1991. It requires doctors to report each case to the coroner, who in turn notifies the public prosecutor. Ultimately, the Assembly of Prosecutors General decides whether to prosecute. Although physician-assisted death remains technically illegal, doctors are extremely unlikely to be prosecuted if they comply with the requirements for accepted practice. In 1995, the ministers of health and justice commissioned an evaluation to determine the adequacy of the notification procedure. A random sample of 405 physicians were interviewed. We also interviewed 147 physicians who had reported cases of physician-assisted death and 116 coroners, and we reviewed 353 judicial files of reported cases. In addition, we interviewed 48 public prosecutors and reviewed the minutes of the Assembly of Prosecutors General for 1991 to 1995 and all published court decisions from 1981 through 1995. In 1995, about 41 percent of all cases of euthanasia and physician-assisted suicide were reported. There were no major differences between reported and unreported cases in terms of the patients' characteristics, clinical conditions, or reasons for the action. Most patients had cancer and were described as suffering "unbearably" and 'hopelessly." Of the 6324 cases reported during the period from 1991 through 1995, only 13 involved prosecution of the physician. The majority of respondents in the groups interviewed thought that all cases of physician-assisted death should be reviewed, although most doctors thought the review should be performed by other doctors, and there was substantial concern about the burden associated with the reporting procedure. Substantial progress in the oversight of physician-assisted death has been achieved in the Netherlands. The reporting procedure could be more streamlined and less threatening.
Article
This article has no abstract; the first 100 words appear below. The Supreme Court has unanimously ruled that there is no constitutional right to physician-assisted suicide.¹,² Unexpectedly, however, the Court did much more than simply uphold the New York and Washington statutes prohibiting assisted suicide. A Court majority effectively required all states to ensure that their laws do not obstruct the provision of adequate palliative care, especially for the alleviation of pain and other physical symptoms of people facing death. The plaintiffs in these cases demanded a “right to die” with physician assistance, not a right to adequate palliative care. The defendant states — Washington and New York — countered . . . Robert A. Burt, J.D. Yale Law School, New Haven, CT 06520
The road to nowhere. Sydney: Four Corners Television Production, Australian Broadcasting Commission
  • M Mclaughlin
Australian psychiatry and euthanasia
  • Ryan