End games: euthanasia under interminable scrutiny

It is increasingly asserted that the disagreements of abstract principle between adversaries in the euthanasia debate fail to account for the complex, particular and ambiguous experiences of people at the end of their lives. A greater research effort into experiences, meaning, connection, vulnerability, and motivation is advocated, during which the euthanasia 'question' should remain open. I argue that this is a normative strategy, which is felicitous to the status quo and further medicalises the end of life, but which masquerades as a value-neutral assertion about needing more knowledge.     

Nurse participation in decisions regarding limitation of treatment.

A vast literature exists on the ethical aspects of decisions to limit life-sustaining treatments, and much of it deals with the way decisions ought to be made. Little is known, however, about how decisions are made in actual clinical practice. Empirical studies have not investigated the decision-making process directly and, with one exception, have only focused on physician practices. Through the use of a case, this paper examines the nature of hospital cancer nurses' involvement in the decision-making process. Three practice domains are identified: assisting patients to reach a truly autonomous choice, helping families to understand and to cope with the realities of the situation, and communicating with and encouraging open communication among all those involved. In addition, the potential value of the in-between position of the nurse is noted, and nurse responsibilities are summarized.     

Combining control measures for more effective management of fisheries under uncertainty: quotas, effort limitation and protected areas

We consider combinations of three types of control measures for the management of fisheries when the input information for policy decisions is uncertain. The methods considered include effort controls, catch quotas and area closures. We simulated a hypothetical fishery loosely based on the Icelandic cod fishery, using a simple spatially explicit dynamic model. We compared the performance with respect to conserving the resource and economic return for each type of control measure alone and in combination. In general, combining more than one type of primary direct control on fishing provides a greater buffer to uncertainty than any single form of fishery control alone. Combining catch quota control with a large closed area is a most effective system for reducing the risk of stock collapse and maintaining both short and long-term economic performance. Effort controls can also be improved by adding closed areas to the management scheme. We recommend that multiple control methods be used wherever possible and that closed areas should be used to buffer uncertainty. To be effective, these closed areas must be large and exclude all principal gears to provide real protection from fishing mortality.     

Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey

Background

Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.

Methods

We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.

Results

The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient’s explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.

Interpretation

Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.Euthanasia and physician-assisted suicide are heavily debated issues in medical practice. In recent years, three European countries (Belgium and the Netherlands in 2002, and Luxemburg in 2009) and two US states (Oregon in 1997 and Washington State in 2009) decriminalized euthanasia and physician-assisted suicide under formal conditions.^1–5 Canada is among a number of countries where the debate over legalization has flared up, with a proposed bill reaching Parliament and a pro-euthanasia proposal by the Quebec College of Physicians.⁶Understandably, the issue of euthanasia triggers much emotion and can be fraught with speculative arguments. Opponents of euthanasia often argue that legalizing the procedure will lead to a rise in the use of life-ending drugs without a patient’s explicit request, especially in vulnerable patient groups.^7–10 Thus far, however, no indications of this have been found in studies of physician-assisted deaths before and after legalization in Belgium and the Netherlands.^9,11,12 In Belgium, the percentage of deaths in which life-ending drugs were used remained stable, and the proportion without an explicit request from the patient decreased.¹² Other studies have shown that euthanasia, physician-assisted suicide and the use of life-ending drugs without explicit patient request are not confined to countries where physician-assisted death is legal.^13–16In addition to knowing the overall occurrence of physician-assisted death, it is equally important for an adequately informed, empirically based debate to know its performance in vulnerable patient groups and the care put into the decision and performance. In light of legalization and its alleged effects on the use of life-ending drugs without patient request, it is also important to map similarities and differences between euthanasia and the use of life-ending drugs without explicit patient request. In this article, we report our investigation of demographic and clinical characteristics associated with physician-assisted deaths in Flanders, Belgium; the involvement of the patient, relatives and other caregivers in the decision-making process; reasons for the decisions; aspects of the treatment trajectory; and details of the performance in terms of drug use and the people administering the life-ending drugs.     

Gibbon foraging decisions and the marginal value model

We use data from an observational field study of frugivory in two sympatric gibbons, lar (Hylobates lar) and siamang (H. syndactylus), to test assumptions and predictions of the marginal value model (MVM). A key prediction of the MVM is that marginal gain rates at the time of leaving the patch are equal across patch types. We found that this is not the case for gibbons: rates of energy intake at the end of feeding sessions were significantly different for different types of fruit, and we could not attribute this to temporal variation in fruit availability. Initial and final caloric intake rates were highly correlated. This suggests that gibbons do not adjust the time spent in patches in order to maximize the average rate of energy intake. Similar results were obtained for all other currencies considered. Gibbon foraging appears to satisfy several, but not all, assumptions of the MVM. As required by the model, fruit patches occur as discrete units, patches are encountered sequentially, travel time between patches exceeds search time between items within a patch, search for and search within patches are incompatible activities, and intake rates decline over time spent in a patch. However, the declining rates we detected may be an effect of satiation instead of patch depletion, patches probably are not encountered at random, and group members may not forage independently. Thus, our results suggest that the MVM is not an adequate model of gibbon foraging behavior, but they do not invalidate the MVM per se.     

The effect of mouse euthanasia technique on subsequent lymphocyte proliferation and cell mediated lympholysis assays

The purpose of this study was to determine the effects that specific euthanasia methods have on mitogen induced lymphocyte proliferation (LP) and the induction of alloantigen specific cytolytic T-lymphocytes (CTL). Mice were euthanatized by cervical dislocation (CD), or anesthesia with methoxyflurane or pentobarbital followed by CD (M-CD or P-CD respectively), CO2 overexposure (CO2-OD) or halothane overexposure (H-OD). Mitogenic lymphoproliferation was increased in cells derived from mice euthanatized by M-CD and P-CD. In contrast, the cytolytic profile of CTL derived from mice euthanatized by P-CD, CO2-OD and H-OD was decreased. The results of this study show that euthanasia techniques involving the use of methoxyflurane, pentobarbital, CO2 and halothane affect in vitro lymphoproliferation and CTL function. We conclude that the method of euthanasia influences certain immunologic parameters and selection of a particular technique should be given careful consideration.     

Multi-attribute mate choice decisions and uncertainty in the decision process: a generalized sequential search strategy

The behavior of females in search of a mate determines the likelihood that high quality males are encountered and adaptive search strategies rely on the effective use of available information on the quality of prospective mates. The sequential search strategy was formulated, like most models of search behavior, on the assumption that females obtain perfect information on the quality of encountered males. In this paper, we modify the strategy to allow for uncertainty of male quality and we determine how the magnitude of this uncertainty and the ability of females to inspect multiple male attributes to reduce uncertainty influence mate choice decisions. In general, searchers are sensitive to search costs and higher costs lower acceptance criteria under all versions of the model. The choosiness of searchers increases with the variability of the quality of prospective mates under conditions of the original model, but under conditions of uncertainty the choosiness of searchers may increase or decrease with the variability of inspected male attributes. The behavioral response depends on the functional relationship between observed male attributes and the fitness return to searchers and on costs associated with the search process. Higher uncertainty often induces searchers to pay more for information and under conditions of uncertainty the fitness return to searchers is never higher than under conditions of the original model. Further studies of the performance of alternative search strategies under conditions of uncertainty may consequently be necessary to identify search strategies likely to be used under natural conditions.     

Pollen limitation affects progeny vigour and subsequent recruitment in the insect-pollinated herb Ranunculus acris

Pollen limitation on seed production appears to be widespread among the angiosperms. However, few studies have examined if pollen limitation affects population growth. We supplementally hand-pollinated all flowers of 20 individuals of Ranunculus acris in the temperate meadow Rudsviki, Kaupanger, west Norway in 2003. The seed production did not respond to pollen addition, but the achene weight increased by 18% after supplemental pollination. To test whether this progeny quality response to the pollen-supplementation experiment could contribute to population growth, we sowed achenes from hand-pollinated plants and control plants into natural conditions in ten blocks at three densities. During the subsequent season (2004), the number of seedlings and juveniles (pooled) from hand-pollinated plants were substantially (64%) higher than from controls. There was also a clear positive effect of seed sowing-density on recruitment, suggesting that recruitment is seed-limited in this system. However, the density of vegetative individuals in 2005 was generally low and did not differ significantly between plots that received achenes from control or supplementary pollinated plants. Our results show that pollen limitation may affect germination through seed quality, and thereby impact plant population dynamics. However, in our system it appears that other factors, such as intra- and interspecific competition, may have outweighed the potential contribution from pollen limitation on population demography.     

Managing uncertainty: information and insurance under the risk of starvation

In an uncertain world, animals face both unexpected opportunities and danger. Such outcomes can select for two potential strategies: collecting information to reduce uncertainty, or insuring against it. We investigate the relative value of information and insurance (energy reserves) under starvation risk by offering model foragers a choice between constant and varying food sources over finite foraging bouts. We show that sampling the variable option (choosing it when it is not expected to be good) should decline both with lower reserves and late in foraging bouts; in order to be able to reap the reduction in uncertainty associated with exploiting a variable resource effectively, foragers must be able to afford and compensate for an initial increase in the risk of an energetic shortfall associated with choosing the option when it is bad. Consequently, expected exploitation of the varying option increases as it becomes less variable, and when the overall risk of energetic shortfall is reduced. In addition, little activity on the variable alternative is expected until reserves are built up early in a foraging bout. This indicates that gathering information is a luxury while insurance is a necessity, at least when foraging on stochastic and variable food under the risk of starvation.     

The accountant as triage master: an economist's perspective on voluntary euthanasia and the value of life debate

The author, an economist, rebuts the contention that human life cannot and should not be economically evaluated and argues that such evaluations are made implicitly and inconsistently, resulting in a reduction of human welfare. He presents an economic framework for the analysis of costs and benefits in which the focal point, as in most value systems, is the tradeoff between life and quality of life. Therefore, as the quality of life decreases, society's efforts to preserve life should decrease. If the valuation of life includes self evaluation, then there should be less effort to preserve the life of an individual who wishes to die. Richardson concludes that voluntary euthanasia is a limiting case in which society accepts the individual's valuation of life.     

Optimal stopover decisions under wind influence: the effects of correlated winds

Wind speed and direction have a significant effect on a flying bird's ground speed. Migrants are therefore expected to be sensitive to wind conditions and this should have consequences for optimal strategies of stopover and refuelling. Based on an earlier model of time-minimizing migration which includes wind condition, we investigate the consequences of the temporal correlation of wind conditions. Day-to-day changes in wind conditions are modelled with a two-state Markov process and an expression for the expected speed of migration is derived. The policy of the migrants is described by two parameters: a day t(g) when the birds start to leave whenever favourable conditions occur and a later day t(b)when they leave even in unfavourable winds. The model predicts that in most cases departures should be close to the date which is predicted by a wind-free deterministic model and that the birds should never leave without wind assistance. Only if the probability that the condition remains the same on the following day is close to 1 should the birds leave even in unfavourable conditions shortly after the deterministic optimal date. If the transition matrix is highly asymmetrical, i.e. if it is very probable that unfavourable conditions remain and that favourable conditions will change into unfavourable, then the birds are predicted to start using good winds several days before the deterministic optimal date. An analysis of six years of wind data from two sites in Sweden shows that wind directions on successive days are in fact correlated in all years.     

Risk management decisions for pesticides and threatened and endangered species: The role of uncertainty analysis

Despite data gaps and information shortfalls, government agencies in the United States are expected to produce timely and defensible decisions to regulate pesticide use under the Federal Insecticide, Fungicide, and Rodenticide Act and in compliance with the Endangered Species Act. The decision to register a pesticide is predicated on a conclusion that no unreasonable effects will accrue to the environment, including threatened and endangered species. We recognize that the definition of acceptable risk is a policy judgment stemming from legislative language and judicial interpretation. However, a common risk assessment approach with similar technical underpinnings and a high degree of transparency used by all the agencies would be cost effective and more likely to achieve consensus among interested parties. Quantitative probabilistic risk assessment (PRA) methods can be used to develop risk estimates and to describe the level of confidence in these estimates. PRA methods can also differentiate among the contributions of natural stochasticity, measurement variability, and lack of knowledge. Because this approach enhances transparency and increases understanding of the implications of limited data sets and associated assumptions, we encourage the appropriate agencies to implement PRA methods as a means of reaching common ground when assessing risks of pesticides to listed species.     

Dynamic modelling under uncertainty: the case of Trypanosoma brucei energy metabolism

Kinetic models of metabolism require detailed knowledge of kinetic parameters. However, due to measurement errors or lack of data this knowledge is often uncertain. The model of glycolysis in the parasitic protozoan Trypanosoma brucei is a particularly well analysed example of a quantitative metabolic model, but so far it has been studied with a fixed set of parameters only. Here we evaluate the effect of parameter uncertainty. In order to define probability distributions for each parameter, information about the experimental sources and confidence intervals for all parameters were collected. We created a wiki-based website dedicated to the detailed documentation of this information: the SilicoTryp wiki (http://silicotryp.ibls.gla.ac.uk/wiki/Glycolysis). Using information collected in the wiki, we then assigned probability distributions to all parameters of the model. This allowed us to sample sets of alternative models, accurately representing our degree of uncertainty. Some properties of the model, such as the repartition of the glycolytic flux between the glycerol and pyruvate producing branches, are robust to these uncertainties. However, our analysis also allowed us to identify fragilities of the model leading to the accumulation of 3-phosphoglycerate and/or pyruvate. The analysis of the control coefficients revealed the importance of taking into account the uncertainties about the parameters, as the ranking of the reactions can be greatly affected. This work will now form the basis for a comprehensive Bayesian analysis and extension of the model considering alternative topologies.     

Phenotypic heterogeneity of microbial populations under nutrient limitation

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Alberta euthanasia survey: 1. Physicians' opinions about the morality and legalization of active euthanasia.

OBJECTIVE: To ascertain the opinions of a sample of Alberta physicians about the morality and legalization of active euthanasia, the determinants of these opinions and the frequency and sources of requests for assistance in active euthanasia. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Of the respondents 44% did believe that it is sometimes right to practice active euthanasia; 46% did not. Moral acceptance of active euthanasia correlated with type of practice and religious affiliation and activity. In all, 28% of the physicians stated that they would practice active euthanasia if it were legalized, and 51% indicated that they would not. These opinions were significantly related to sex, religious affiliation and activity, and country of graduation. Just over half (51%) of the respondents stated that the law should be changed to permit patients to request active euthanasia. Requests (usually from patients) were reportedly received by 19% of the physicians, 78% of whom received fewer than five. CONCLUSIONS: This survey revealed severely disparate opinions among Alberta physicians about the morality of active euthanasia. In particular, religious affiliation and activity were associated with the polarized opinions. The desire for active euthanasia, as inferred from requests by patients, was not frequent. Overall, there was no strong support expressed by the physicians for the personal practice of legalized active euthanasia. These data will be vital to those involved in health education and public policy formation about active euthanasia in Alberta and the rest of Canada.     

Impact of market value on human mate choice decisions

Mate choice strategies are a process of negotiation in which individuals make bids that are constrained by their status in the market place. Humans provide an unusual perspective on this because we can measure their explicitly expressed preferences before they are forced to make any choices. We use advertisements placed in newspaper personal columns to examine, first, the extent to which evolutionary considerations affect the level of competition (or market value) during the reproductively active period of people's lives and, second, the extent to which market value influences individual's willingness to make strong demands of prospective mates. We show that female market value is determined principally by women's fecundity (and, to a lesser extent, reproductive value), while male market value is determined by men's earning potential and the risk of future pairbond termination (the conjoint probability that the male will either die or divorce his partner during the next 20 years). We then show that these selection preferences strongly influence the levels of demands that men and women make of prospective partners (although older males tend to overestimate their market value).     

Parameter uncertainty in LCA: stochastic sampling under correlation

Purpose  

At the parameter level, data inaccuracy, data gaps, and the use of unrepresentative data have been recognized as sources of uncertainty in life cycle assessment (LCA). In many LCA uncertainty studies, parameter distributions were created based on the measured variability or on “rules of thumb,” but the possible existence of correlation was not explored. The correlation between parameters may alter the sampling space and, thus, yield unrepresentative results. The objective of this article is to describe the effect of correlation between input parameters (and the final product) on the outcome of an uncertainty analysis, carried out for an LCA of an agricultural product.