Attitudes among NHS doctors to requests for euthanasia.

OBJECTIVES--To explore NHS doctors'' attitudes to competent patients'' requests for euthanasia and to estimate the proportion of doctors who have taken active steps to hasten a patient''s death. DESIGN--Anonymous postal questionnaire, with no possibility of follow up. The survey was conducted from December 1992 to March 1993. SUBJECTS--All (221) general practitioners and 203 hospital consultants in one area of England. RESULTS--273 doctors responded to a question on whether a patient had ever asked them to hasten death. Of these, 163 had been asked to; 124 of these had been asked to take active steps to hasten death; 38 of 119 (32%) of these had complied with such a request (95% confidence interval 23% to 40%). This proportion represented 12% of all those who returned a completed questionnaire and 9% of all those who had been sent a questionnaire (95% confidence interval 6.3% to 11.7%). A larger proportion of the respondents (142/307 (46%)), however, would consider taking active steps to bring about the death of a patient if it was legal to do so. CONCLUSIONS--Many doctors face difficult decisions about euthanasia. For the benefit of both patients and doctors euthanasia should be discussed more openly.     

Voluntary euthanasia: a utilitarian perspective

Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life--if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.     

The Metabolism of the Volatile Amines: IV. The Role of Drugs in the Pathogenesis of Hepatic Encephalopathy

The effects of certain drugs on metabolism of ammonia by the liver and kidneys in dogs were investigated by a technique in which both hepatic inflow and outflow bloods could be repeatedly sampled in unanesthetized healthy animals. Specific representatives of the classes of the drugs studied included thiopental (barbiturates), morphine (opiates and analgesics), promazine (tranquillizers), and chlorothiazide (oral diuretics).The three drugs commonly used as sedatives were all found to impair the ability of the liver to metabolize ammonia. The diuretic, by contrast, increased the amount of ammonia put into the systemic system by the kidneys. Ethanol appeared to have little or no direct effect on ammonia metabolism.The possibility exists that the occurrence of acute hepatic encephalopathy in patients with severe liver disease may be avoided in many cases if these drugs are administered with proper care. Results also indicated that current concepts of the pharmacological action of sedatives, opiates and tranquillizers may require revision.     

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.     

The legal investigation of a decision not to operate on an infant with Down's syndrome and a duodenal atresia: a report from the Netherlands

It is well-known that in the Netherlands it has for several years been possible to carry out voluntary euthanasia quite openly, provided certain strict conditions are fulfilled. This situation has arisen because courts in the Netherlands have decided that doctors who end the lives of their patients under these conditions are in a "conflict of duties" situation, and therefore should not be convicted of any criminal offence. It has, however, not been known what view a Netherlands court might take about life and death decisions concerning patients who are not capable of giving consent -- for example, infants. This report briefly outlines my experience in the case of an infant with Down's syndrome and duodenal atresia -- a blockage of the digestive system that must be operated upon if the infant is to survive. A decision was taken not to operate, and this decision resulted in the Netherlands courts considering whether criminal proceedings were justified.     

Illness, suffering and voluntary euthanasia

It is often accepted that we may legitimately speak about voluntary euthanasia only in cases of persons who are suffering because they are incurably injured or have an incurable disease. This article argues that when we consider the moral acceptability of voluntary euthanasia, we have no good reason to concentrate only on persons who are ill or injured and suffering.     

Public attitudes toward euthanasia and suicide for terminally ill persons: 1977 and 1996

This study replicates Singh's (1979) "classic" examination of correlates of euthanasia and suicide attitudes. The purposes of the current study were to assess (1) changes in public attitudes toward these voluntary termination of life practices, and (2) changes in the effects on attitudes of selected independent variables. I found Americans' approval of both euthanasia and suicide in 1996 to be higher than that in 1977. The increase in the approval of suicide, however, far outstripped that of euthanasia. Results of OLS regressions indicated that race, religious commitment, religious attendance, political identification, and suicide approval were statistically significant predictors of euthanasia approval. Only religious attendance and euthanasia approval were statistically significant predictors of suicide approval in both 1977 and 1996. The findings regarding euthanasia approval support those of Singh (1979); those regarding suicide approval do not. Triangulation of methods in future research is necessary to illuminate other aspects of these multifaceted issues.     

The ethics of euthanasia: advocates' perspectives

The Netherlands is currently the only country in the world in which euthanasia is legally permissible. More specifically, Dutch law (briefly explained) allows that a doctor terminates the life of a patient of hers on his voluntary, well-considered and sustained request, if he is suffering unbearably and hopelessly. The aim of this paper is to reconstruct the Dutch debate on the moral permissibility of euthanasia so as to clarify and strengthen the various views that can be advanced in support of euthanasia. On the one view, The Pure Autonomy View (TPAV), the justification of euthanasia rests solely on the principle of respect for autonomy. That is, the reason for performing and permitting euthanasia is the patient's voluntary, well-considered and sustained, in one word: autonomous, request for euthanasia. On the alternative view, The Joint View (TJV), the principle of respect for autonomy and the principle of beneficence morally justify euthanasia together . That is, euthanasia is ethical if and partly because, since the patient is suffering unbearably and hopelessly, euthanasia is in his interest. According to this paper, there is no easy argument for one of these views rather than the other. Instead, as yet both TPAV and TJV seem inherently problematic. TPAV is unable to give a doctor a reason for performing euthanasia that appeals to her in her capacity as a doctor, such as relief of suffering. And TJV begs the question – for example, if a state were to legalize euthanasia on grounds of TJV, it would force the view upon its citizens that it may be in a person's interest to die.     

Euthanasia and the active-passive distinction

The author examines various claimed differences between active and passive euthanasia and, if there are differences, whether they are morally significant. He refutes arguments based on acting vs. not acting, intention, double effect, cause of death, and natural law theory. Reichenbach proposes that the most helpful distinction is the one between intentional killing (active euthanasia) and appropriate treatment for the dying or terminally ill (passive euthanasia). Significant moral difference, however, rests on the contention that intentional killing is always wrong and that, all else being equal, dying by natural means is intrinsically good, whereas dying by unnatural means is not.     

Legal Standards for Brain Death and Undue Influence in Euthanasia Laws

A major appellate court decision from the United States seriously questions the legal sufficiency of prevailing medical criteria for the determination of death by neurological criteria. There may be a mismatch between legal and medical standards for brain death, requiring the amendment of either or both. In South Australia, a Bill seeks to establish a legal right for a defined category of persons suffering unbearably to request voluntary euthanasia. However, an essential criterion of a voluntary decision is that it is not tainted by undue influence, and this Bill falls short of providing adequate guidance to assess for undue influence.     

NARRATIVES OF ‘TERMINAL SEDATION’, AND THE IMPORTANCE OF THE INTENTION‐FORESIGHT DISTINCTION IN PALLIATIVE CARE PRACTICE

The moral importance of the ‘intention–foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end‐of‐life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in‐depth interviews to address the use of sedation at the end of life. The majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one's intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation – cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles.     

'Bioethics' is subordinate to morality in Japan

Disputes over brain death and euthanasia are used to illuminate the question whether there really is a Japanese way of thinking in bioethics. In Japanese thought, a person does not exist as an individual but as a member of the family, community or society. I describe these features of Japanese society as 'mutual dependency'. In this society, an act is 'good' and 'right' when it is commonly done, and it is 'bad' and 'wrong' when nobody else does it. Thus, outsiders to this ring of mutual dependency encounter ostracism. One feature of this society is a lack of open discussion which leads to the existence of multiple standards. This Japanese morality even prevails over written laws. In Japan, there is a public stance that euthanasia does not exist. On the other hand, there are certain decisions which have permitted euthanasia. Similarly, organ transplants were performed from brain dead donors, while that procedure was not accepted officially by the medical profession. In this situation, there is a danger that human rights will be neglected. So far bioethical approaches have not helped to work out these problems. This may be because Japanese think that bioethics is subordinate to morality. The current dispute over brain death involves a struggle for the establishment of a rational society in Japan. Overcoming mutual dependency and ostracism is essential to resolve this struggle and to lead Japan into a society of mutual respect where all individuals, families and communities are esteemed.     

Perioperative management of cosmetic liposuction

Recent qualms about the safety of aesthetic lipoplasty may be attributable more to support system flaws than to technical process deficiencies. The authors here focus on perfunctory patient monitoring when sedative or analgesic drugs are given, cavalier infiltration of mega-dose lidocaine, cursory intraoperative patient observation by team members with conflicting responsibilities, anesthesia providers unfamiliar with the unique surgical physiology of liposuction, hurried-discharge policies that virtually ignore the residual depressant effects of sedatives and analgesics, and compressive dressings that impair postoperative chest-wall expansion and venous return. Whereas pulmonary embolism remains the leading process cause of morbidity from liposuction, complications from austere resource allocation to dedicated patient monitoring should be largely preventable. Not all lipoplasties require an anesthesia provider but-when heavy sedation, mega-dose lidocaine, or both, are projected-a trained team member dedicated exclusively to patient safety and comfort should be a minimum patient care standard. The potential role of lidocaine cardiotoxicity in tumescent anesthesia is widely underappreciated and that of hypothermia goes mostly unrecognized. These, plus largely preventable or potentially correctable perioperative events such as pulmonary edema, fluid imbalance, or improperly administered sedative and analgesic drugs, demand upgrading and expansion of monitoring, resuscitative, and recuperative facilities in physician offices. In fact, ASPS guidelines urge that anesthesia services be engaged for dedicated patient care whenever "major" liposuction or conscious sedation is projected, because liposuction is neither as benign nor as simple a procedure as heretofore reputed. To assess objectively the operative and anesthetic risk of obesity, document body mass index for the preoperative record; morbid obesity (body mass index >/= 35.0), for instance, is a known risk multiplier for sedatives and analgesics. Other system issues such as the dynamic profile of high-dose lidocaine pharmacokinetics, the deportation of fat globules in the bloodstream, and the incidence of intraoperative hypothermia remain as unresolved topics for interdisciplinary, multi-institutional clinical research.     

Final report of the Netherlands State Commission on Euthanasia: an English summary

An unofficial summary is provided of the Final Report of the Netherlands State Commission on Euthanasia, submitted to the Minister of Welfare, Health and Cultural Affairs and the Minister of Justice on 19 Aug 1985. It describes the establishment of the State Commission, its working methods, and its recommendations for changes in the Criminal Code with regard to euthanasia and assisted suicide. The Commission proposes that the Code be amended so that the intentional termination of another person's life at the latter's request would not be an offense if carried out by a doctor on a patient who is "in an untenable situation with no prospect of improvement." It makes recommendations regarding minors, the mentally handicapped, and prisoners, and regarding procedures for funeral arrangements and death certificates, the noninvolvement of parties other than patients and physicians in decision making, and the preparation and dispensing of drugs designed to terminate life.     

A GOOD DEATH: WHO BEST TO BRING IT?*

The author supports the right of persons to terminate their lives when it would be in their "best interests" to do so. He considers cases in which persons are unable to kill themselves and request euthanasia or have requested it beforehand in a living will. Crisp rejects relatives, friends, and most physicians as the agents to carry out the request because of the emotional trauma to the agents and the damage to the image of physicians as savers of lives. He proposes that the practice of euthanasia be part of "telostrics," an area of medical specialization in the care of the terminally ill, and that these "telostricians" should perform voluntary euthanasia.     

‘EARLY TERMINAL SEDATION’ IS A DISTINCT ENTITY

There has been much discussion regarding the acceptable use of sedation for palliation. A particularly contentious practice concerns deep, continuous sedation given to patients who are not imminently dying and given without provision of hydration or nutrition, with the end result that death is hastened. This has been called ‘early terminal sedation’. Early terminal sedation is a practice composed of two legally and ethically accepted treatment options. Under certain conditions, patients have the right to reject hydration and nutrition, even if these are life‐sustaining. Patients are also entitled to sedation as palliation for intolerable, intractable suffering. Though early terminal sedation is thought to be rare at present, the changing nature of palliative medicine suggests its use will increase. Arguments regarding early terminal sedation have failed to recognize early terminal sedation as a distinct legal and ethical entity. It can be seen as both the simple sum of treatment refusal and sedation for palliation, analogous to terminal sedation. It can also be seen as an indivisible palliative treatment, more analogous to assisted suicide or euthanasia. But ultimately, it is wholly analogous neither to terminal sedation given when death is imminent, nor to assisted suicide or euthanasia. This paper contends that early terminal sedation should be considered as a distinct entity. Such a reconception promises to provide a way forward in the debate, practice and policy regarding this contentious area of palliative medicine.     

The impact of reporting cases of euthanasia in Holland: a patient and family perspective

In 1991 the Dutch government released the results of the first national investigation into the nature and extent of decisions concerning end of life including euthanasia. A significant finding was that most cases of euthanasia were not reported. This prompted us to ask what effect, if any, not reporting caused. More specifically, we asked whether reporting has a positive or negative impact on the experiences of friends or relatives of patients who have received euthanasia. In cases of euthanasia, complications of both process and experience can deter from a minimally complicated death. These difficulties arise when either the family or physician does not perceive the freedom to disclose euthanasia openly. On the basis of interviews with family members and patients, we illustrate that they generally benefit from reporting. Our premise is that reporting fosters open discussion of euthanasia. We further suggest physicians and society benefit from a milieu of openness initiated by reporting cases of euthanasia.