Against homeopathy--a utilitarian perspective

I examine the positive and negative features of homeopathy from an ethical perspective. I consider: (a) several potentially beneficial features of homeopathy, including non-invasiveness, cost-effectiveness, holism, placebo benefits and agent autonomy; and (b) several potentially negative features of homeopathy, including failure to seek effective healthcare, wastage of resources, promulgation of false beliefs and a weakening of commitment to scientific medicine. A utilitarian analysis of the utilities and disutilities leads to the conclusion that homeopathy is ethically unacceptable and ought to be actively rejected by healthcare professionals.     

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.     

Alcohol dependence associated with increased utilitarian moral judgment: a case control study

Recent studies indicate that emotional processes, mediated by the ventromedial prefrontal cortex (VMPC), are of great importance for moral judgment. Neurological patients with VMPC dysfunction have been shown to generate increased utilitarian moral judgments, i.e. are more likely to endorse emotionally aversive actions in order to maximize aggregate welfare, when faced with emotionally salient personal moral dilemmas. Patients with alcohol dependence (AD) also exhibit impairments in functions mediated by the prefrontal cortex, but whether they exhibit increased utilitarian moral reasoning has not previously been investigated. The aim of this study was to investigate moral judgment in AD patients (n = 20) compared to healthy controls (n = 20) matched by sex, age and education years. Each subject responded to a battery of 50 hypothetical dilemmas categorized as non-moral, moral impersonal and moral personal. They also responded to a questionnaire evaluating explicit knowledge of social and moral norms. Results confirmed our hypothesis that AD patients generated increased utilitarian moral judgment compared to controls when faced with moral personal dilemmas. Crucially, there was no difference in their responses to non-moral or impersonal moral dilemmas, nor knowledge of explicit social and moral norms. One possible explanation is that damage to the VMPC, caused by long term repeated exposure to alcohol results in emotional dysfunction, predisposing to utilitarian moral judgment. This work elucidates a novel aspect of the neuropsychological profile of AD patients, namely a tendency to generate utilitarian moral judgment when faced with emotionally salient moral personal dilemmas.     

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.     

Grooming in primates: Implications for its utilitarian function

Captive lion-tailed macaques, ring-tailed lemurs and Celebes black “apes” performed relatively more social grooming of areas which are inaccessible to self-grooming. Combined with considerable circumstantial evidence, this suggests that primate grooming may subserve real utilitarian functions in parasite removal, in addition to its acknowledged social functions.     

Animal genetic manipulation--a utilitarian response

I examine the process and outcomes of animal genetic manipulation ('transgenesis') with reference to its morally salient features. I consider several objections to transgenesis. I examine and reject the alleged intrinsic wrongness of 'deliberate genetic sequence alteration', as I do the notion that transgenesis may lead to human genetic manipulation. I examine the alleged wrongness of killing inherent in transgenesis, and suggest that the concept of 'replaceability' successfully justifies such killing, although not for entities deemed to possess 'personhood'. I examine 'significant suffering' associated with transgenesis and propose the radical conclusion that, although it would be wrong to prohibit animal genetic manipulation per se, utilitarians ought to support a 'default prohibition' on transgenic experiments that entail significant suffering.     

Hepatoimmunology: a perspective

Premises for the subspecialty of hepatoimmunology include the recognition that the liver is a lymphoid organ with unique immunological properties. These properties ensure efficient innate defence against intestinal microbes and toxins, confer a particular capacity for induction of tolerance, and provide for apoptotic disposal of redundant lymphocytes. Pathological responses within the liver are elicited when: (i) hepatotropic viruses (hepatitis virus B and C) escape immune elimination and reside in hepatocytes; (ii) the liver becomes the site of autoimmune responses directed against either hepatocytes (autoimmune hepatitis) or biliary ductules (primary biliary cirrhosis); or (iii) the liver in the course of disposal of drugs generates neoantigens that provoke adverse allergic responses. Recent advances in the understanding of the immunopathogenesis of these entities are reviewed.     

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.     

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.     

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.