First do no harm: pressing concerns regarding euthanasia in Belgium

Neurology ethics at the end of life

Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.

Outcomes from organ donation following medical assistance in dying: A scoping review

AIM

To collate and summarize the current international literature on the transplant recipient outcomes of organs from Medical Assistance in Dying (MAiD) donors, as well as the actual and potential impact of organ donation following MAiD on the donation and transplantation system.

BACKGROUND

The provision of organ donation following MAiD can impact the donation and transplantation system, as well as potential recipients of organs from the MAiD donor, therefore a comprehensive understanding of the potential and actual impact of organ donation after MAiD on the donation and transplantation systems is needed.

DESIGN

Scoping review using the JBI framework.

METHODS

We searched for published (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Academic Search Complete), and unpublished literature (organ donation organization websites worldwide). Included references discussed the actual and potential impact of organ donation following MAiD on the donation and transplantation system. All references were screened, extracted and analysed by two independent reviewers.

RESULTS

We included 78 references in this review and our finding were summarized across three categories: (1) Impact in the donor pool: (2) statistics on organ donation following MAiD; and (3) potential and actual impact of MAiD on the donation and transplant system.

CONCLUSIONS

The potential impact of the MAiD donor on the transplant waiting list is relatively small as this process is still rare, however, due to the current organ shortage worldwide the contribution of this procedure should not be disregarded. Additionally, despite being limited, the existing research provided scanty evidence that organs retrieved from MAiD donors are associated with satisfactory graft function and survival rates and that outcomes from transplant recipients are comparable to those of organs from donation following brain death and may be better than those of organs from other types of donation after circulatory determined death. Still, further studies are required for comprehensive and reliable evidence.

Nurses attitudes towards death, dying patients and euthanasia: A descriptive study

Background:

Attitudes of nurses towards death and related concepts influence end-of-life care. Determining nurses’ views and attitudes towards these concepts and the factors that affect them are necessary to ensure quality end-of-life care.

Objectives:

The purpose of this study was to determine nurses’ views and attitudes about death, dying patient, euthanasia and the relationships between nurses’ characteristics.

Methods:

Participants consist of the nurses who volunteered to take part in this descriptive study from 25 hospitals (n = 340) which has a paediatric or adult intensive care unit and located within the boundaries of Ankara, Turkey. ‘Nurse Information Form’ and ‘Attitude Scale about Euthanasia, Death and Dying Patients (DAS)’ were used as data collection tool.

Ethical consideration:

Written permissions were received from the ‘Noninterventional Clinical Researches Ethics Board’ of authors’ university and education councils of each hospital. Informed consent was obtained from participants.

Findings:

It is found that there are statistically significant difference among the factors of marital status, having a child, years of experience, bereavement experience, affected by working with dying patient, definition of euthanasia, views about patients who are appropriate for euthanasia, views about patients who desire to die and feeling need for counselling on these concepts according to the mean total score of nurses’ attitudes about euthanasia, death and dying patient (p < 0.05).

Conclusion:

The results indicate that nurses are negatively affected to face the concepts of death, euthanasia and work with dying patient. This is reflected in their attitude. In order to gain positive attitude towards death, dying patient and euthanasia, the implementation of training and consulting services to nurses at appropriate intervals during both education and professional life are required.

Responses to assisted suicide requests: an interview study with Swiss palliative care physicians

Objectives

Assisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians’ involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.

Methods

A qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.

Results

Swiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patient’s request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients’ wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.

Conclusions

The Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner’s values, but may not correspond to patients’ expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.

First Do No Harm: Euthanasia of Patients with Dementia in Belgium

In Memory of Ed Pellegrino. Euthanasia in Belgium is not limited to terminally ill patients. It may be applied to patients with chronic degenerative diseases. Currently, people in Belgium wish to make it possible to euthanize incompetent patients who suffer from dementia. This article explains the Belgian law and then explores arguments for and against euthanasia of patients with dementia. It probes the dementia paradox by elucidating Dworkin's distinction between critical and experiential interests, arguing that at the end-of-life this distinction is not clearcut. It argues against euthanasia for patients with dementia, for respecting patients' humanity and for providing them with more care, compassion, and good doctoring.

The legal status of suicide: A global review

Copies were obtained of the criminal codes from 192 countries and states; in 25 suicide is currently illegal, and an additional 20 countries follow Islamic or Sharia law where suicide attempters may be punished with jail sentences. The vast majority of countries have laws making it illegal to abet, aid or encourage suicide, but the nature and punishment of the actions that are illegal varies. Laws in places with Civil, Common Law, Islamic Law and Traditional Law systems are compared. Great variances in application were noted, sometimes within countries. It is impossible to estimate the number of persons currently in jail for having attempted suicide, but jail sentences are still given to suicide attempters. Some countries do not prosecute suicide attempters despite the laws, while others consistently jail suicide attempters. In countries where suicide attempts have been decriminalized, attempters may still face prosecution when another person is injured or dies as a result of their suicide attempt or where the attempter is a member of the military. We discuss the roots of laws making suicide, aiding, and encouraging suicide illegal and examine prospects for future changes. The recent Supreme Court Decision in Canada, invalidating the law making it illegal to assist in the suicide of physically ill people who are suffering (abeit with restrictive conditions) illustrates current trends towards "liberalization" of assisted suicide.

Questions and answers on the Belgian model of integral end-of-life care: experiment? Prototype? : "Eu-euthanasia": the close historical, and evidently synergistic, relationship between palliative care and euthanasia in Belgium: an interview with a doctor involved in the early development of both and two of his successors

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?

Background

Following the 2002 enactment of the Belgian law on euthanasia, which requires the consultation of an independent second physician before proceeding with euthanasia, the Life End Information Forum (LEIF) was founded which provides specifically trained physicians who can act as mandatory consultants in euthanasia requests. This study assesses quality of consultations in Flanders and Brussels and compares these between LEIF and non-LEIF consultants.

Methods

A questionnaire was sent in 2009 to a random sample of 3,006 physicians in Belgium from specialties likely involved in the care of dying patients. Several questions about the last euthanasia request of one of their patients were asked. As LEIF serves the Flemish speaking community (i.e. region of Flanders and the bilingual Brussels Capital Region) and no similar counterpart is present in Wallonia, analyses were limited to Flemish speaking physicians in Flanders and Brussels.

Results

Response was 34%. Of the 244 physicians who indicated having received a euthanasia request seventy percent consulted a second physician in their last request; in 30% this was with a LEIF physician. Compared to non-LEIF physicians, LEIF physicians were more often not a colleague (69% vs 42%) and not a co-attending physician (89% vs 66%). They tended to more often discuss the request with the attending physician (100% vs 95%) and with the family (76% vs 69%), and also more frequently helped the attending physician with performing euthanasia (44% vs 24%). No significant differences were found in the extent to which they talked to the patient (96% vs 93%) and examined the patient file (94% vs 97%).

Conclusion

In cases of explicit euthanasia requests in Belgium, the consultation procedure of another physician by the attending physician is not optimal and can be improved. Training and putting at disposal consultants through forums such as LEIF seems able to improve this situation. Adding stipulations in the law about the necessary competencies and tasks of consulting physicians may additionally incite improvement. Irrespective of whether euthanasia is a legal practice within a country, similar services may prove useful to also improve quality of consultations in various other difficult end-of-life decision-making situations.