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Physician assisted suicide: The great Canadian Euthanasia debate

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Abstract

A substantial majority of Canadians favours a change to the Criminal Code which would make it legally permissible, subject to careful regulation, for patients suffering from incurable physical illness to opt for either physician assisted suicide (PAS) or voluntary active euthanasia (VAE). This discussion will focus primarily on the arguments for and against decriminalizing physician assisted suicide, with special reference to the British Columbia case of Lee Carter vs. Attorney General of Canada. The aim is to critique the arguments and at the same time to describe the contours of the current Canadian debate. Both ethical and legal issues raised by PAS are clarified. Empirical evidence available from jurisdictions which have followed the regulatory route is presented and its relevance to the slippery slope argument is considered. The arguments presented by both sides are critically assessed. The conclusion suggested is that evidence of harms to vulnerable individuals or to society, consequent upon legalization, is insufficient to support continued denial of freedom to those competent adults who seek physician assistance in hastening their death.
... Concerns arise with the ability to provide consent if the patient is experiencing profound suffering as such suffering may impair judgement (Dean, Cellarius, Henry, Oneschuk, & Librach, 2012;Materstvedt & Bosshard, 2009). In addition, informed consent requires that patients possess an understanding of their prognosis as well as all treatment options (including no treatment as an option) before providing consent (Schafer, 2013). In the context of MAiD, in contrast to PS, consent is mandatory and must be provided by the patient immediately before the provision of MAiD (Government of Canada, 2018). ...
... PS, thus, represents a potential option for those unable to consent, such as when capacity has been lost, to have their suffering relieved. The predominant concern with the patient or ADM not providing consent is the potential for abuse or inappropriate use, particularly concerning vulnerable individuals (Schafer, 2013). Indeed, it has been argued that it is much easier and less expensive to initiate sedation rather than to manage complex symptoms (Bruce & Boston, 2011;Rady & Verheijde, 2010). ...
... The exception is when there has been experience with a family member or friend who has undergone PS. Awareness of both PS and MAiD is essential in order to ensure patients and families have access to information about all possible treatment options integral to informed consent (Schafer, 2013). (Bruinsma et al., 2013). ...
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Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for clinicians and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada.
... A eutanásia e o suicídio assistido encontram suas bases no princípio bioético da autonomia, segundo o qual o paciente tem o direito de decidir quando e onde morrer, e esses atos também podem diminuir seu sofrimento durante o processo de morte 6 . Porém existem impedimentos morais e religiosos, que argumentam não ser eticamente correto ajudar alguém a morrer 7 . ...
... Também há o argumento da "ladeira escorregadia" (slippery slope, em inglês), segundo o qual a legalização do suicídio assistido ou da eutanásia tornaria difícil ou impossível proteger pacientes vulneráveis, como idosos e deficientes, de erros e abusos 7 . Entretanto, rigorosos critérios de segurança, como os utilizados em países onde essas práticas são legalizadas, podem fornecer proteção adequada contra excessos 7 . ...
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Resumo Objetivou-se identificar a atitude de profissionais e acadêmicos de enfermagem, fisioterapia, medicina e psicologia de um hospital universitário perante suicídio assistido e eutanásia. O estudo foi desenvolvido por meio de questionário de autopreenchimento e contou com 354 participantes, entre os quais, 68,1% concordaram com a legalização do suicídio assistido e 73,2% com a legalização da eutanásia para pacientes com doenças terminais. A concordância com a legalização do suicídio assistido ou da eutanásia foi de 46,9% em casos de pacientes com doenças neurodegenerativas progressivas e de 30,8% em casos de tetraplegia. Em casos de doenças terminais, se legalizados, 45% dos participantes cometeriam suicídio assistido, 57% solicitariam eutanásia, 36,5% auxiliariam suicídio assistido e 39,9% auxiliariam eutanásia. Conclui-se que a ampla aceitação da legalização da eutanásia e do suicídio assistido entre os participantes enfatiza a necessidade de se ampliar a discussão sobre o tema entre a população.
... It is further believed that the 'Nazi slippery slope' argument can be avoided by having additional safeguards and/or regulations that would require precautions to be enforced by law, as is the case in many countries where these practices have already been legalised. [16,18] ...
... These are not easy issues to resolve. The late twentieth and early twenty-first century provides several examples of legislators at national and subnational levels of government engaged in protracted debates about issues related to end of life decision-making (see Van der Heide et al., 2007;Bartels and Otlowski, 2010;Ganzini et al., 2000;Schafer, 2013). That said, issues of morality and ethics are recognized and codified in several manners. ...
Article
This article captures the implications of technology supportive of high level autonomous vehicles eclipsing the capacity of regulators to respond. To date, policy makers and industry actors have avoided confronting the impending gap, a consequence of the fact that current levels of vehicle autonomy are sufficiently low that accountability for decision-making affecting the operation of vehicles still resides with the driver. However, as automotive firms achieve higher levels of vehicle autonomy and control shifts to the vehicle itself and the infrastructure supporting it, the preponderance of responsibility will transfer to different actors: automotive firms, autonomous vehicle programmers, and policy makers. This article explains and quantifies the challenges that will arise as that process unfolds. It does this by introducing four ethics and value-based foundations that can be used to guide programming of decisions to be made by autonomous vehicles. The purpose is not to recommend a specific ethics or value-based foundation for programming high level autonomous vehicles. Rather, by programming dilemma-inducing scenarios and then directing outcomes on the basis of distinct ethical or values-based foundations, we quantifiably demonstrate that autonomous vehicle programming decisions, whether they are guided by a particular ethical foundation or moral code or not, manifest in tangibly different outcomes. Through this, we introduce and discuss challenges – many not considered previously – associated with programming and regulating high level autonomous vehicles. Based on that, we consider implications for policy as well as the long-term proliferation of the technology.
... The practice of palliative sedation ("to the point of causing unconsciousness and hastening death") has been used in courts in North America as an argument against the need for legalizing PAS. In court decisions the two practices are placed side by side, separated by a lawfulness criterion and the seemingly arbitrary proclamation that the former is morally preferable to the latter, as long as it operates under the DDE (Schafer, 2013). This means that even if the life-shortening effect of CDS might be rare, its potential to hasten death is not fully excluded, because the strict rules under which sedation to unconsciousness is condoned derive exactly from accepting this possibility. ...
Article
Debates on morally acceptable and lawful end-of-life (EOL) practices in pediatrics were reignited by the recent amendment in Belgian law to allow euthanasia for minors of any age who meet the criteria for capacity. Euthanasia and its legalization in pediatrics are often opposed based on the availability of aggressive palliative sedation. For terminally ill patients, this type of sedation is often identified as continuous and deep sedation until death (CDS). We demonstrate that this reasoning is based on flawed assumptions: (1) CDS is a morally preferable alternative to euthanasia; (2) CDS can meet the same patient needs as euthanasia; (3) children lack the capacity and experience to make EOL decisions; (4) unlike euthanasia, CDS does not raise capacity issues. Our aim is not to reject CDS as a valid option at the EOL, nor to offer a clear-cut defense of euthanasia for minors, but to emphasize the ethical issues with both practices.
... It is further believed that the 'Nazi slippery slope' argument can be avoided by having additional safeguards and/or regulations that would require precautions to be enforced by law, as is the case in many countries where these practices have already been legalised. [16,18] ...
Article
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For many years, euthanasia and physician-assisted suicide (PAS) have been topics that no one dared to mention. However, over the past few decades, the subject has emerged as a very pertinent issue around the world, for a number of reasons – so much so that these life-ending practices have already been legalised or decriminalised in some developed countries, such as Belgium, the Netherlands and Switzerland, and within certain states of the USA. In the states and countries where the practices have been legalised, or at least decriminalised, the effects of the legalisation have been relatively well documented. On the other hand, in countries like South Africa (SA), where they are illegal, whether or not they should be legalised (taking into consideration all the associated benefits and consequences) should be discussed, and a consensus reached, sooner rather than later. A consensus regarding the feasibility of legalising euthanasia and/or PAS in SA is needed because these practices (or mere requests for them) are becoming increasingly common, especially among people with terminal illnesses. Furthermore, the relative ease with which patients who desperately seek to end their life through either of the aforementioned methods, and are able to access them – by applying for them in countries where the pertinent laws and regulations are adjudged to be more liberal – is alarming. This highlights the importance and need for each country to set clear laws or parameters (and regulations, where applicable) that relate to these life-ending practices.
Book
*** The book is written in Thai (การตัดสินใจในระยะท้ายของชีวิตกับสังคมไทย: บทเรียนจากประสบการณ์ของต่างประเทศ) and is downloadable at: https://www.khonthai4-0.net/?p=3725
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The subject of this research is the legal and moral-ethical framework of euthanasia (“a good death”) in such BRICS countries as Brazil, Russia and China from the perspective of analysis of the current regulatory and other acts and documents, doctrine, opinions of legal and medical experts, who provide pros and cons of such measure as euthanasia. The raised questions are viewed and analyzed from the position of an alternative to the previously researched aspects of therapeutic cloning, bioprinting (3D printing), growing organs and tissue that are developed and implemented in the context of the idea “No One Should Die”. The scientific novelty of this work is substantiated by articulation of the problem (examination from the perspective of law and moral-ethical perceptions), choice of countries (BRICS member-states), and analysis of the most recent materials (for example, Law of the People's Republic of China “On Basic Healthcare and Health Promotion” passed on December 28, 2019 (effected on June 1, 2020); Resolution of the Ministry of Health of Brazil of October 31, 2018 No.41 “On Recommendation for Organization of Palliative Care within the framework of Help Provided Through Unified Healthcare System”), and earlier, but also relevant acts and documents (Law of the Russian Federation of November 21, 2011 No. 323-FZ “On the Basis of Health Protection of Citizens in the Russian Federation”, amended on April 34, 2020, etc.). A conclusion is made that euthanasia could be only active and voluntary, when a decision is made by a person with incurable disease, of sound mind, who comprehends the actions and their consequences.
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In 2014, Québec became the first province in Canada to allow medical assistance in dying (MAID) by adopting the Act Respecting End-of-Life Care. This was, and still is, an important policy change. It involves a singular and highly moral issue that generated debates spanning over a longer period than that specific to the law’s development and adoption. Using French and English newspapers’ renderings of these debates in Québec between 2005 and 2015, this study deconstructs MAID’s journey in the province into four periods, each characterized by a specific narrative: flexible precaution, legal hypocrisy, accountability imperative, and ineluctable adaptation. These four narratives allow us to better understand MAID’s framing process as they reveal the underlying rationales of three overarching frames covering the 2005–2015 period: the legal frame, the social progress frame and the service provision frame.
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Throughout this chapter, medically related suicide—mental illness, assisted suicide and euthanasia—will be explored. This exploration presents definitions, patterns, forms and themes within the relevant literature in order not only to highlight the realities of different types of suicides but also to illustrate the key areas of relevant research that have been and are being undertaken. The three types of medical suicide cover the forms of suicide experienced most typically within society. As such, these three examples are surrounded by much stigma and controversy and debates continue both in academia and in society around the many related issues, from prevention of suicide in patients with mental illnesses to the devaluation of disability that assisted suicide/euthanasia can generate.
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John Hardwig created a major stir in the bioethics and health care ethics communities when he published his provocative article “Is There a Duty to Die?” In response to this article, Rosemarie Tong argues that individuals have no duty—either to family members, other loved ones, or society—to die. First, Tong summarizes Hardwig’s arguments on behalf of a duty to die, particularly his view of this duty as a moral obligation or responsibility as opposed to a legal duty. Second, she outlines five points in the case against a duty to die: 1. It seems inappropriate to hinge the duty to die on whether or not a person is fortunate enough to have a family, loved ones, or another type of web of human relationships. 2. Given our present society, in which health care expenses and managed care regulations influence the giving of less medical treatment instead of the giving of all possible treatments, considerations of a duty to die are inappropriate until standards are set for managed care treatment, for example. 3. A duty to die will not be perceived equally by the sexes and therefore may be discriminatory toward women who may feel pressured to accept a duty to die, because men are typically socialized to think of their individual rights and women are typically socialized to think of their communal responsibilities. 4. Instead of a “duty” to die, the concept might be better understood as the “option” to die, a choice that people are free to make. 5. Instead of using the language of duty and obligation, the concept should be described in the language of caring and choice. Finally, Tong concludes that in our present individualistic and rights-oriented society, it is not safe to posit a duty to die. Until all members of society are considered on equal terms, the duty to die will not be imposed on citizens equally.
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Ethical and legal issues concerning assisted suicide and euthanasia are very much on the public agenda in many jurisdictions. This book addresses these issues within the wider context of palliative care for patients in the dying process. Its ethical conclusion is that a bright line between assisted death and other widely accepted end-of-life practices, including the withdrawal of life-sustaining treatment, pain control through high-dose opioids, and terminal sedation, cannot be justified. In the course of the ethical argument many familiar themes are given careful and thorough treatment: conceptions of death, the badness of death, informed consent and refusal, suicide, cause of death, the double effect, the sanctity of life, the 'active/passive' distinction, advance directives, and non-voluntary euthanasia. The legal discussion opens with a survey of some prominent prohibitionist and regulatory regimes and then outlines a model regulatory policy for assisted death. The book concludes by defending this policy against a wide range of common objections, including those which appeal to slippery slopes or the possibility of abuse, and by asking how the transition to a regulatory regime might be managed in three common law prohibitionist jurisdictions.
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Context The Oregon Death with Dignity Act, passed by ballot measure in 1994 and enacted in October 1997, legalized physician-assisted suicide for competent, terminally ill Oregonians, but little is known about the effects of the act on clinical practice or physician perspective.Objective To examine Oregon physicians' attitudes toward and practices regarding care of dying patients since the passage of the Death with Dignity Act.Design, Setting, and Participants A self-administered questionnaire was mailed in February 1999 to Oregon physicians eligible to prescribe under the act. Of 3981 eligible physicians, 2641 (66%) returned the questionnaire by August 1999.Main Outcome Measures Physicians' reports of their efforts to improve care for dying patients since 1994, their attitudes, concerns, and sources of information about participating in the Death with Dignity Act, and their conversations with patients regarding assisted suicide.Results A total of 791 respondents (30%) reported that they had increased referrals to hospice. Of the 2094 respondents who cared for terminally ill patients, 76% reported that they made efforts to improve their knowledge of the use of pain medications in the terminally ill. Nine hundred forty-nine responding physicians (36%) had been asked by a patient if they were potentially willing to prescribe a lethal medication. Seven percent of all survey participants reported that 1 or more patients became upset after learning the physician's position on assisted suicide, and 2% reported that 1 or more patients left their care after learning the physician's position on assisted suicide. Of the 73 physicians who were willing to write a lethal prescription and who had received a request from a patient, 20 (27%) were not confident they could determine when a patient had less than 6 months to live.Conclusion Most Oregon physicians who care for terminally ill patients report that since 1994 they have made efforts to improve their ability to care for these patients and many have had conversations with patients about assisted suicide.
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In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency. We assessed frequency and characteristics of euthanasia, physician-assisted suicide, and other end-of-life practices in 2010, and assessed trends since 1990. In 1990, 1995, 2001, 2005, and 2010 we did nationwide studies of a stratified sample from the death registry of Statistics Netherlands, to which all deaths and causes were reported. We mailed questionnaires to physicians attending these deaths (2010: n=8496 deaths). All cases were weighted to adjust for the stratification procedure and for differences in response rates in relation to the age, sex, marital status, region of residence, and cause and place of death. In 2010, of all deaths in the Netherlands, 2·8% (95% CI 2·5-3·2; 475 of 6861) were the result of euthanasia. This rate is higher than the 1·7% (1·5-1·8; 294 of 9965) in 2005, but comparable with those in 2001 and 1995. Distribution of sex, age, and diagnosis was stable between 1990 and 2010. In 2010, 77% (3136 of 4050) of all cases of euthanasia or physician-assisted suicide were reported to a review committee (80% [1933 of 2425] in 2005). Ending of life without an explicit patient request in 2010 occurred less often (0·2%; 95% CI 0·1-0·3; 13 of 6861) than in 2005, 2001, 1995, and 1990 (0·8%; 0·6-1·1; 45 of 5197). Continuous deep sedation until death occurred more frequently in 2010 (12·3% [11·6-13·1; 789 of 6861]) than in 2005 (8·2% [7·8-8·6; 521 of 9965]). Of all deaths in 2010, 0·4% (0·3-0·6; 18 of 6861) were the result of the patient's decision to stop eating and drinking to end life; in half of these cases the patient had made a euthanasia request that was not granted. Our study provides insight in consequences of regulating euthanasia and physician-assisted suicide within the broader context of end-of-life practices. In the Netherlands the euthanasia law resulted in a relatively transparent practice. Although translating these results to other countries is not straightforward, they can inform the debate on legalisation of assisted dying in other countries. The Netherlands Organization for Research and Development (ZonMw).
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This widely cited chapter was one of the first to analyze the importance of gender and feminist theory in the debate over whether to legitimate physician-assisted suicide and euthanasia. The author argues that the usual debate is about a patient who does not exist - one with no gender or insurance status. Yet there is ample reason to suspect that gender, among other factors, deserves analysis. The prominent cases in the U.S. debate mostly feature women patients. Data show that dimensions of health status and health care that affect a patient’s vulnerability to considering physician-assisted suicide and euthanasia - including depression, poor pain relief, and difficulty obtaining good care - differentially plague women. Suicide patterns themselves show a strong gender effect: women less often complete suicide but more often attempt it. And women still face social circumstances marred by sexism, particularly women with illness, disability, or advanced age. This chapter thus examines four potential gender effects: an effect on the incidence of assisted suicide and euthanasia by sex; differences in the reasons women seek assisted suicide and euthanasia, in part based on the long history of valorizing women’s self-sacrifice; a difference in the doctor-patient dynamic for female patients seeking assisted suicide or euthanasia, especially if physicians may be susceptible to affirming women’s negative self-judgments; and a gender effect in the public debate, reflecting the sense that the cases featuring female patients fit cultural stereotypes and so seem 'right.' The chapter analyzes the available data, and the way gender figures in our cases, cultural imagery, and health care practice.The chapter then brings feminist critiques and theoretical tools to bear. The debate over assisted suicide and euthanasia focuses on precisely the kinds of issues on which much feminist work has focused: what it means to talk about rights of self-determination and autonomy; the reconciliation of those rights with physicians’ duties of beneficence and caring; and how to place all of this in a context including the strengths and failures of families, professionals, and communities, as well as real differences of power and resources. The chapter criticizes the usual argument that patients’ rights of self-determination legitimate physician-assisted suicide and euthanasia, on the grounds that this misconstrues the utility of rights talk for resolving this debate, and ignores essential features of the context. Nor does the usual appeal to physician beneficence and "mercy" provide resolution, as it typically relies on a shallow understanding of physician care. The author elaborates what a deeper and contextualized understanding demands and argues that physicians as professional caregivers should be guided by a notion of "principled caring." Finally, the author suggests what a proper integration of rights and caring requires, and how it can be coupled with attention to the actual circumstances and fate of women.
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This anonymous postal survey explored attitudes and experiences concerning end-of-life decisions. Respondents were English-speaking members of the Canadian Association for Nurses in AIDS Care (CANAC) and other nurses identified as working primarily in HIV/AIDS settings. Seventy-three percent believed that the law should be changed to allow physicians to practice voluntary euthanasia (VE) and assisted suicide (AS). Fifty-three percent indicated that nurses should be allowed to practice VE and AS. Although VE and AS are illegal, fewer than one in five nurses would report a colleague whom they knew to be involved in such acts. More than one in five nurses have received requests from patients to hasten their deaths by VE. Nearly 98% believe that the nursing profession should be involved in policy development concerning VE and AS, and nearly 78% believe that nurses should be involved in the decision-making process with patients if such acts were legal. Given that ethical codes for Canadian nurses promote client self-determination and that nurses are the largest group of care providers for the terminally ill, the profession must promote discussion and research if it is to take a leadership role with respect to end-of-life issues.
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