Euthanasia, consensual homicide, and refusal of treatment

Consensual homicide remains a crime in jurisdictions where active voluntary euthanasia has been legalized. At the same time, both jurisdictions, in which euthanasia is legal and those in which it is not, recognize that all patients (whether severely ill or not) have the right to refuse or withdraw medical treatment (including life-saving treatment). In this paper, I focus on the tensions between these three norms (the permission of active euthanasia, the permission to reject life-saving treatment, and the prohibition of consensual homicide), assuming a justification of euthanasia based on the right to (personal) autonomy. I argue that the best way to provide a coherent account of these norms is to claim that patients have two distinct rights: the right to autonomy and the right to bodily integrity. This solution has some relevant implications for the discussion of the legalization of active euthanasia.

Killing in the name of: A merciful death?

"Mercy" holds a well-established place in the discourse on assisted death (AD), with mercy rhetoric used by both proponents and opponents of AD alike. In this paper, I interrogate the relationship between mercy, mercy killing and AD. Appeals to mercy introduce an ambiguity that carries implications for the enduring debate about healthcare professionals' participation in this controversial practice. The term "mercy killing" is used at different times to mean all of the following: killings that are acts of punitive leniency, killings motivated by pity, killings motivated by compassion, and acts of voluntary, involuntary and nonvoluntary euthanasia. I argue that killings that are acts of punitive leniency "track" a conceptually useful understanding of mercy and, by extension, mercy killing. However, if mercy is understood in this way, then "mercy killing" is a problematic way of characterizing physician-AD. While reference to mercy killing has been weeded out of AD legislation over time, the same cannot be said of public discourse, where the debate about physicians' character-and the locus of power with respect to who gets to decide when a life can rightly be ended-continues.

Vital prostheses: Killing, letting die, and the ethics of de-implantation

Disconnecting a patient from artificial life support, on their request, is often if not always a matter of letting them die, not killing them-and sometimes, permissibly doing so. Stopping a patient's heart on request, by contrast, is a kind of killing, and rarely if ever a permissible one. The difference seems to be that procedures of the first kind remove an unwanted external support for bodily functioning, rather than intervening in the body itself. What should we say, however, about cases at the boundary-procedures involving items that seem bodily in some respects, but not others? When, for instance, does deactivating an implanted device like a pacemaker count as killing, and when as letting die? Contra existing proposals, I argue that the boundaries of the body for this purpose are not drawn at the boundaries of the self, or (if this is different) the human organism. Nor should we determine when we are killing and when we are letting die by deferring to existing practices for distinguishing ongoing from completed treatment. Rather, I argue that whether something (organic or inorganic) counts as body part for purposes of this distinction depends on the results of a normative analysis of the particular character of our rights in it-particularly, whether and in what way these rights ought to be alienable. I conclude by arguing that there are likely good reasons to recognize distinctively "bodily" rights and restrictions in at least some implantable devices.

How do people use 'killing', 'letting die' and related bioethical concepts? Contrasting descriptive and normative hypotheses

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

What passive euthanasia is

BACKGROUND

Euthanasia can be thought of as being either active or passive; but the precise definition of "passive euthanasia" is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all such withholding should be seen as passive euthanasia.

MAIN TEXT

At the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life-sustaining treatment is passive euthanasia is traced to James Rachels's arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels's arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent.

SHORT CONCLUSION

James Rachels's work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist.

Comparison of attitudes towards five end-of-life care interventions (active pain control, withdrawal of futile life-sustaining treatment, passive euthanasia, active euthanasia and physician-assisted suicide): a multicentred cross-sectional survey of Korean patients with cancer, their family caregivers, physicians and the general Korean population

OBJECTIVES

This study determined attitudes of four groups-Korean patients with cancer, their family caregivers, physicians and the general Korean population-towards five critical end-of-life (EOL) interventions-active pain control, withdrawal of futile life-sustaining treatment (LST), passive euthanasia, active euthanasia and physician-assisted suicide.

DESIGN AND SETTING

We enrolled 1001 patients with cancer and 1006 caregivers from 12 large hospitals in Korea, 1241 members of the general population and 928 physicians from each of the 12 hospitals and the Korean Medical Association. We analysed the associations of demographic factors, attitudes towards death and the important components of a 'good death' with critical interventions at EoL care.

RESULTS

All participant groups strongly favoured active pain control and withdrawal of futile LST but differed in attitudes towards the other four EoL interventions. Physicians (98.9%) favoured passive euthanasia more than the other three groups. Lower proportions of the four groups favoured active euthanasia or PAS. Multiple logistic regression showed that education (adjusted OR (aOR) 1.77, 95% CI 1.33 to 2.36), caregiver role (aOR 1.67, 95% CI 1.34 to 2.08) and considering death as the ending of life (aOR 1.66, 95% CI 1.05 to 1.61) were associated with preference for active pain control. Attitudes towards death, including belief in being remembered (aOR 2.03, 95% CI 1.48 to 2.79) and feeling 'life was meaningful' (aOR 2.56, 95% CI 1.58 to 4.15) were both strong correlates of withdrawal of LST with the level of monthly income (aOR 2.56, 95% CI 1.58 to 4.15). Believing 'freedom from pain' negatively predicted preference for passive euthanasia (aOR 0.69, 95% CI 0.55 to 0.85). In addition, 'not being a burden to the family' was positively related to preferences for active euthanasia (aOR 1.62, 95% CI 1.39 to 1.90) and PAS (aOR 1.61, 95% CI 1.37 to 1.89).

CONCLUSION

Groups differed in their attitudes towards the five EoL interventions, and those attitudes were significantly associated with various attitudes towards death.

The sensitivity argument against child euthanasia

Is there a moral difference between euthanasia for terminally ill adults and euthanasia for terminally ill children? Luc Bovens considers five arguments to this effect, and argues that each is unsuccessful. In this paper, I argue that Bovens' dismissal of the sensitivity argument is unconvincing.

Support for Voluntary Euthanasia with No Logical Slippery Slope to Non-Voluntary Euthanasia

This paper demonstrates that acceptance of voluntary euthanasia does not generate commitment to either non-voluntary euthanasia or euthanasia on request. This is accomplished through analysis of John Keown's and David Jones's slippery slope arguments, and rejection of their view that voluntary euthanasia requires physicians to judge patients as better off dead. Instead, voluntary euthanasia merely requires physicians to judge patients as within boundaries of appropriate deference. This paper develops two ways of understanding and defending voluntary euthanasia on this model, one focused on the independent value of patients' autonomy and the other on the evidence of well-being provided by patients' requests. Both avoid the purported slippery slopes and both are independently supported by an analogy to uncontroversial elements of medical practice. Moreover, the proposed analyses of voluntary euthanasia suggest parameters for the design of euthanasia legislation, both supporting and challenging elements of existing laws in Oregon and the Netherlands.

Active and Passive Physician-Assisted Dying and the Terminal Disease Requirement

The view that voluntary active euthanasia and physician-assisted suicide should be made available for terminal patients only is typically warranted by reference to the risks that the procedures are seen to involve. Though they would appear to involve similar risks, the commonly endorsed end-of-life practices referred to as passive euthanasia are available also for non-terminal patients. In this article, I assess whether there is good reason to believe that the risks in question would be bigger in the case of voluntary active euthanasia and physician-assisted suicide than in that of passive euthanasia. I propose that there is not. On that basis, I suggest that limiting access to voluntary active euthanasia and physician-assisted suicide to terminal patients only is not consistent with accepting the existing practices of passive euthanasia.

Killing or letting die? Proposal of a (somewhat) new answer to a perennial question

There is as yet no widely agreed-upon solution to the standard textbook problem whether actively shutting off a life-sustaining medical device, e.g. a respirator, and thus bringing about a patient's death amounts to active killing or just to an omission of further treatment. Apart from a range of astutely contrived case examples and respective particular solutions proposed in the literature, there seems to be no consensus on the normative principles such solutions should be grounded in, not even on the need for such principles beyond sheer intuition. The present paper attempts to develop a normative approach based on fundamental principles of law. From this perspective, what is decisive for the question of 'killing or letting die' in such cases is not that death ensues from a behaviour that is active and relevantly causative, but rather, whether or not the agent in performing the deadly act transgresses the boundaries of the domain of his or her sole normative authority, and thereby intervenes in the protected sphere of another. Unless he or she does so, their behaviour cannot be classified as active commission regardless of the amount of causal activity it may display and regardless of its potentially harmful consequences. This conception is spelled out in detail and tested in a range of case examples, as are several of its corollaries that deviate from standard type solutions.

Death, treatment decisions and the permanent vegetative state: evidence from families and experts

Some brain injured patients are left in a permanent vegetative state, i.e., they have irreversibly lost their capacity for consciousness but retained some autonomic physiological functions, such as breathing unaided. Having discussed the controversial nature of the permanent vegetative state as a diagnostic category, we turn to the question of the patients' ontological status. Are the permanently vegetative alive, dead, or in some other state? We present empirical data from interviews with relatives of patients, and with experts, to support the view that the ontological state of permanently vegetative patients is unclear: such patients are neither straightforwardly alive nor simply dead. Having defended this view from counter-arguments we turn to the practical question as to how these patients ought to be treated. Some relatives and experts believe it is right for patients to be shifted from their currently unclear ontological state to that of being straightforwardly dead, but many are concerned or even horrified by the only legally sanctioned method guaranteed to achieve this, namely withdrawal of clinically assisted nutrition and hydration. A way of addressing this distress would be to allow active euthanasia for these patients. This is highly controversial; but we argue that standard objections to allowing active euthanasia for this particular class of permanently vegetative patients are weakened by these patients' distinctive ontological status.

[General practitioner and palliative sedation]

Recent publications in Dutch national newspapers on palliative sedation have raised concerns about its use in general practice. There is now evidence that there is no significant increase in the incidence of palliative sedation. Euthanasia requests were pending in 20.8% of the cases in which palliative sedation was performed, but the general practitioners could clearly justify why they made this choice. This is important because it indicates that they are aware of a sharp distinction between euthanasia and palliative sedation. Although the decision to perform palliative sedation was discussed with almost all cancer patients, patient involvement was less present in non-cancer conditions. This may be related to different disease trajectories, but it also indicates that attention should be devoted to earlier identification of patients in need of palliative care. The findings confirm that the practice of palliative sedation by general practitioners largely reflects the recommendations of the Dutch National Guideline on Palliative Sedation.

[Written advance directives in dementia: useful and relevant]

According to the Dutch euthanasia law, the current wishes of the patient can be replaced by an advance directive if the patient is unable to give consent. However, Dutch physicians say they have difficulty responding to advance directives in people with dementia. A crucial issue is how to establish whether the patient actually suffers in a specific situation. We argue that the patient's wishes, views and decisions should be discussed in a timely manner, and laid down both in patient directives and in the doctor's files. We also ask for regular discussion, updating and reaffirmation of the advance directive so that the patient can trust the doctor knowing the patient's wishes and what constitutes unbearable suffering for that patient. Through frequent discussion and reaffirmation, the advance directive can play the role intended by the law on euthanasia.

Markers for heightened monitoring, imminent death, and euthanasia in aged inbred mice

The goal of this study was to identify objective criteria that would reliably predict spontaneous death in aged inbred mice. We evaluated male and female AKR/J mice, which die at a relatively young age due to the development of lymphoma, as well as male C57BL/6J and BALB/cByJ mice. Mice were implanted subcutaneously with an identification chip that also allowed remote measurement of body temperature. Temperatures and body weights were measured weekly until spontaneous death occurred or until euthanasia was performed for humane reasons. In AKR/J mice, hypothermia and weight loss began about 4 wk prior to death and increased gradually during that antemortem interval. In C57BL/6J and BALB/cByJ mice, these declines began earlier and were more prolonged prior to death. However, C57BL/6J and BALB/cByJ mice developed a relatively precipitous hypothermia during the 2 wk prior to death. For all 3 strains, the derived composite score of temperature × weight, expressed as a percentage of stable values for each mouse, was similarly informative. These changes in individual and composite measures can signal the need for closer observation or euthanasia of individual mice. Validated markers of clinical decline or imminent death can allow the use of endpoints that reduce terminal distress, do not significantly affect longevity or survival data, and permit timely collection of biologic samples.

The Royal College of Nursing guidance on responding to a request to hasten death

In July 2009, when the Royal College of Nursing (RCN) Council in the UK moved to a neutral position on assisted suicide, it also determined that guidance for its members was needed. In October 2011 this guidance was finally published (RCN, 2011). Here the context, scope, and content of this publication are considered.

Exploring the case for assisted dying in the UK

This article discusses the concepts of euthanasia, assisted suicide and physician-assisted suicide, under the umbrella term of assisted dying, from a pro-assisted dying perspective. It outlines the key principles underpinning the debate around assisted dying and refutes the main arguments put forward by those opposing legalisation of assisted dying in the UK.

Do guidelines on euthanasia and physician-assisted suicide in Dutch hospitals and nursing homes reflect the law? A content analysis

To describe the content of practice guidelines on euthanasia and assisted suicide (EAS) and to compare differences between settings and guidelines developed before or after enactment of the euthanasia law in 2002 by means of a content analysis. Most guidelines stated that the attending physician is responsible for the decision to grant or refuse an EAS request. Due care criteria were described in the majority of guidelines, but aspects relevant for assessing these criteria were not always described. Half of the guidelines described the role of the nurse in the performance of euthanasia. Compared with hospital guidelines, nursing home guidelines were more often stricter than the law in excluding patients with dementia (30% vs 4%) and incompetent patients (25% vs 4%). As from 2002, the guidelines were less strict in categorically excluding patients groups (32% vs 64%) and in particular incompetent patients (10% vs 29%). Healthcare institutions should accurately state the boundaries of the law, also when they prefer to set stricter boundaries for their own institution. Only then can guidelines provide adequate support for physicians and nurses in the difficult EAS decision-making process.