On the Moral Acceptability of Physician‐Assisted Dying for Non‐Autonomous Psychiatric Patients

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician‐assisted dying. Yet they typically require that psychiatric‐assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non‐autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric‐assisted dying to autonomous, or rational, psychiatric patients would not be compatible with endorsing certain end‐of‐life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’.     

RECLAIMING THE PATIENT'S VOICE AND SPIRIT IN DYING: AN INSIGHT FROM ISRAEL

In the latter half of the 20th century, Western medicine moved death from the home to the hospital. As a result, the process of dying seems to have lost its spiritual dimension, and become a matter of prolonging material life by means of medical technology. The novel quandaries that arose led in turn to medico‐legal regulation. This paper describes the recent regulation of dying in Israel under its Dying Patient Law, 2005. The Law recognizes advance directives in principle, but limits their effect and form through complex medico‐legal artifices. It reflects a culture that places high value on both scientific medicine and the sanctity of life as such, and illustrates a medical culture that pitches battle against death. At the same time, the Law constructs the will of the individual in a medico‐legal language that is alien to the lay person. The paper suggests an alternative approach to advance care planning that is patient‐centred and addresses the psycho‐social needs of the individual in terms of her relational autonomy. From this perspective, advance care planning becomes an opportunity to extract the patient from the medical context and allow her to speak about her approaching death with close ones in her own terms of reference. To this end, there is a need for facilitation of an intimate encounter where patients can speak about their concerns with their loved ones. The paper also presents a methodological approach of attentive listening, which can be applied across diverse cultures and circumstances.     

Self‐perceived burden to others as a moral emotion in wishes to die. A conceptual analysis

Patients at the end of their life who express a wish to die sometimes explain their wish as the desire not to be a burden to others. This feeling needs to be investigated as an emotion with an intrinsically dialogical structure. Using a phenomenological approach, two key meanings of the feeling of being a burden to others as a reason for a wish to die are identified. First, it is an existential suffering insofar as it contains the perception of a plight so desperate that it can only be relieved by the end of the patient’s existence. Second, it is an empathic concern that implies caring about those who bear the burden of caring for the person at the end of their life. It is therefore a moral emotion, encompassing a series of difficulties, including the subjective perception of a stark imbalance between giving and taking, the adequacy of the representation of the caregiver burden in the patient’s mind, and the danger of diminishing the worth of one’s life out of shame or self‐denigration. R. D. Laing’s terminology of crossed perspectives in interexperience is used to systematically distinguish the actual caregiver burden, the patient’s view of the caregiver burden, the stress for the patient in feeling that s/he is a burden to the caregiver, and the caregiver’s view of the patient’s stress. The sense of being a burden implies the belief that the caregiver feels burdened, and the fear that this burden could become unbearable.     

Emergency Preservation and Resuscitation Trial: A Philosophical Justification for Non‐Voluntary Enrollment

In a current clinical trial for Emergency Preservation and Resuscitation (EPR), Dr. Samuel Tisherman of the University of Maryland aims to induce therapeutic hypothermia in order to ‘buy time’ for operating on victims of severe exsanguination. While recent publicity has framed this controversial procedure as ‘killing a patient to save his life’, the US Army and Acute Care Research appear to support the study on the grounds that such patients already face low chances of survival. Given that enrollment in the trial must be non‐voluntary, the study has received an exemption from federal standards for obtaining informed consent. How exactly, if at all, is non‐voluntary enrollment morally justifiable? In this essay, I appeal to the notable work of Hans Jonas in an effort to defend the EPR trial's use of non‐voluntary enrollment. It is often thought and, as I show, it may appear that Jonas has called for the end of experimental medical practice. Still, I derive from Jonas a principle of double‐effect upon which physicians may be seen as morally permitted to pursue innovations in emergency medicine but only as a byproduct of pursuing therapeutic success. With this position, I argue that the EPR trial can be granted a stronger philosophical justification than simply waiving the requirement of obtaining informed consent. The double‐effect justification would obtain, perhaps regardless of the success of such innovative procedures as therapeutic hypothermia.     

Models for truth‐telling in physician‐patient encounters: What can we learn from Yoruba concept of Ooto?

Empirical studies have now established that many patients make clinical decisions based on models other than Anglo American model of truth‐telling and patient autonomy. Some scholars also add that current medical ethics frameworks and recent proposals for enhancing communication in health professional‐patient relationship have not adequately accommodated these models. In certain clinical contexts where health professional and patients are motivated by significant cultural and religious values, these current frameworks cannot prevent communication breakdown, which can, in turn, jeopardize patient care, cause undue distress to a patient in certain clinical contexts or negatively impact his/her relationship with the community. These empirical studies have now recommended that additional frameworks developed around other models of truth‐telling; and which take very seriously significant value‐differences which sometimes exist between health professional and patients, as well as patient's cultural/religious values or relational capacities, must be developed. This paper contributes towards the development of one. Specifically, this study proposes a framework for truth‐telling developed around African model of truth‐telling by drawing insights from the communitarian concept of oot?? amongst the Yoruba people of south west Nigeria. I am optimistic that if this model is incorporated into current medical ethics codes and curricula, it will significantly enhance health professional‐patient communication.     

Dealing With Death in the Jewish Legal Tradition

The main theme of the article is the tension between the obligation to preserve life, and the value of timely death. This tension is resolved by distinguishing between precipitating death, which is prohibited, and merely removing an impediment to it, which is permitted. In contemporary Jewish law, a distinction is made between therapy, which may be discontinued, and life-support, which must be maintained until the establishment of death. Another theme is that of “soft” patient autonomy, and its role in dealing with the dying in both traditional Jewish law and Israel’s Terminal Patient Law, 2005. Preventing suffering in relation to a dying person, and praying for his or her death are also discussed in the article.     

‘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.     

Dances with data

Conclusion: Medical decisions concerning the end of life are a difficult matter and they evoke much emotional response. What is needed, however, is an open debate in order to improve the moral quality of decision making, not "dances with data". The central question in this debate should be, as Callahan aptly notes, whether medicine should involve itself only in that kind of "suffering which is brought on by illness and dying as biological phenomena" (emphasis added) or whether it should concern itself with the wellbeing of the patient. Apart from the fundamental question as to what types of suffering are to be considered as, at least in part biological phenomena, in The Netherlands most doctors, ourselves included, think the medical profession should do the latter.     

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 thersites complex in plastic surgical patients

Body dysmorphic disorder describes the preoccupation with an imagined defect of appearance. A subgroup of patients suffer from the so-called Thersites complex, in which a minimal physical deformity causes excessive psychological disturbances and distress. Patients with body dysmorphic disorder tend primarily to visit a plastic surgeon for relief with distinct plans for surgical correction of their "deformity." Psychotherapy is generally refused or ineffective. The plastic surgeon should be familiar with this mental disorder and recognize these patients during consultation. Most of these patients should be excluded from surgery; however, patients of the Thersites complex category might be candidates for plastic surgical correction after careful selection. Only the experienced plastic surgeon should make the decision to operate in this situation. A successful treatment can relieve the patient from his or her distress and improve the quality of life substantially. A surgical result that is not accepted by the patient can end in a tragedy for either the patient or the doctor.     

What really is the nature of suffering? Three problems with Eric Cassell’s concept of distress

Eric Cassell famously defined suffering as a person’s severe distress at a threat to their personal integrity. This article draws attention to some problems with the concept of distress in this theory. In particular, I argue that Cassell’s theory turns on distress but does not define it, which, in light of the complexity of distress, problematizes suffering in three ways: first, suffering becomes too equivocal to apply in at least some cases that Cassell nevertheless identifies as suffering; second, Cassell’s account does not explain what sort of experience suffering is, resulting in theoretical and practical difficulties in distinguishing it from other medical conditions; third, there is good reason to believe that, in medical contexts, ‘distress’ just means ‘suffering’ or some cognate concept not yet distinguished from it, rendering Cassell’s theory circular. I consider a rebuttal to my objections and reply, concluding that Cassell’s theory of suffering needs a definition of distress to settle what the nature of suffering really is.     

Public reasoning about voluntary assisted dying: An analysis of submissions to the Queensland Parliament,Australia

The use of voluntary assisted dying as an end‐of‐life option has stimulated concerns and debates over the past decades. Although public attitudes towards voluntary assisted dying (including euthanasia and physician‐assisted suicide) are well researched, there has been relatively little study of the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. Using a mix of computational textual mining techniques, keyword study and qualitative thematic coding to analyse public submissions to a parliamentary inquiry into voluntary assisted dying in Australia, this study critically examines the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. The analysis identified complex and potentially contradictory ethical principles being invoked on both sides of the debate. These findings deepen our understanding of the moral basis of public reasoning about end‐of‐life matters and will help to inform future discussions on policy and law reform. The findings underscore the importance of sound normative reasoning and the use of caution when interpreting opinion polls to inform policy.     

Preparing for (life after) death: Advance care directives and cyclic temporalities

This paper explores the disjuncture between medico‐legal trajectories of living and dying, in which lives start and stop, and the cyclic comings and goings of Buddhist and Hindu bodies. Drawing on fieldwork with Buddhist and Hindu communities in Adelaide, South Australia, I attend to the multiple temporalities that become implicated in end‐of‐life decision‐making about how and when a person may die. Thus, I reorient advance care planning from the linear projection of a single life towards cyclic considerations of the life course. In regarding life and death as ongoing I make space for temporalities of living and dying that run counter to public policy instruments, which focus on an irrevocable, yet calculable, end to life. I demonstrate how advance care planning processes and documents that construct the life course as advancing in a singular, linear and predictable trajectory overlook the multiple temporalities and directions that lives and deaths may take.     

Cultural considerations in forgoing enteral feeding: A comparison between the Hong Kong Chinese,North American,and Malaysian Islamic patients with advanced dementia at the end‐of‐life

Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient‐centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral tube feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision‐making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end‐of‐life care.     

Splitting the Difference? Principled Compromise and Assisted Dying

Compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. When a hotly‐contested phenomenon like assisted dying is debated, all‐or‐nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. In response to recent articles by Søren Holm and Alex Mullock, in this article I argue that principled compromise can be encouraged even in relation to this phenomenon, provided that certain conditions are present (which I suggest they are). In order to qualify as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. The product that will result from such a process will also need to split the difference between the warring parties. In assisted dying, I argue that a reduced offence of ‘compassionate killing’ can achieve this. I acknowledge, however, that splitting the difference can induce splitting headaches, as there remain certain questions to be answered. Hopefully, however, sufficient work is done here to defend attempts to occupy the middle ground, whether these relate to assisted dying specifically or to other disputed moral matters.     

Hesperidin modulates dextran sulfate sodium‐induced ulcerative colitis in rats: Targeting sphingosine kinase‐1‐ sphingosine 1 phosphate signaling pathway,mitochondrial biogenesis,inflammation, and apoptosis

Ulcerative colitis (UC) is a chronic gastrointestinal disorder interfering with life quality. A total of 60 male Wistar rats were divided into four equal groups: Control (group I), hesperidin only (group II), UC untreated (group III), and UC treated with hesperidin (group IV). Hesperidin had modulatory effects on UC pathogenesis, which might be through alleviating colonic sphingosine phosphate phosphatase 2 messenger RNA expression and sphingosine kinase‐1 levels, thus suppressing the subsequent downstream inflammatory and apoptotic cascades represented by decreased macrophage inflammatory protein‐1α and enhancement of B‐cell lymphoma 2 immunohistochemistry expression. Also, it improved mitochondrial biogenesis by increasing the peroxisome proliferator‐activated receptor‐gamma‐coactivator 1‐α level. It successfully restored redox potential as evidenced by marked alleviations of the nitric oxide and peroxynitrite levels, increasing total antioxidant capacity, and activating the superoxide dismutase enzyme. Also, hesperidin alleviated the UC disease activity index and improved the histopathological picture. These findings may offer a new therapeutic strategy for UC treatment.     

Treatment limitation decisions under uncertainty: the value of subsequent euthanasia

This paper examines how decisions to limit treatment to critically ill patients under uncertainty can be made rationally. Expected utility theory offers one way of making rational decisions under uncertainty. One problem with using this approach is that we may not know the value of each option. One rational course open is to treat until further information becomes available. However, treatment can limit the range of options open. With treatment, a patient may recover such that he no longer requires life-supporting treatment. However, his life may be not worth living. If active euthanasia of %on-terminal'conditions is prohibited, the option of dying will no longer be available. Taking a rational'wait and see'course may result in being trapped within an unbearable life. On the other hand, sometimes present practice'lets nature takes its course'. Critically ill patients are allowed to die because it is believed that their lives will be not worth living. It is likely that some patients are allowed to die when there is some objective chance of worthwhile future life. This paper argues that a policy of treating critically ill patients until the nature of future options can be better evaluated, in company with an offer of subsequent euthanasia where appropriate, allows a more rational and humane approach to treatment limitation decisions under uncertainty.     

Evaluación del sufrimiento en la demencia avanzada

Introduction

At the end stage of life of dementia, medical comorbidities are associated with a high degree of patient suffering. The aim of this study was to assess the relationship between the lack of symptoms of discomfort and the level of patient suffering. The relationship with psychological distress and caregiver burden was also clarified.

Material and methods

This study included patients with advanced dementia according to the criteria of the Hospice Enrolment Criteria for End-stage Dementia patients. Patient suffering was assessed with Mini-Suffering State Examination (MSSE). The caregivers were scored by Zarit caregiver burden scale (ZR), and the General Health Questionnaire of Goldberg (GHQ-28). Central tendency and correlation tests were used in the statistical analysis.

Results

The study recorded data from 71 patients. In the comorbidity of medical symptoms associated with advanced dementia, pneumonia (Spearman's rho: −0.29; P=.01), and malnutrition (Spearman's rho: −0.25; P=.03), showed a significant association with the total scale score of MSSE. There were no significant correlations between patient suffering and caregiver psychological distress (r: 0.11; P=.37), or caregiver burden (r: 0.13; P=.32).

Conclusions

The identification of suffering in patients with advanced dementia is recognised by specific symptoms, such as pneumonia and malnutrition. The caregiver’ psychological distress of the caregiver was shown to be unrelated to patient suffering as measured by MSSE.     

Hastening death and respect for dignity: Kantianism at the end of life

Suppose that a young athlete has just become quadriplegic. He expects to live several more decades, but out of self‐interest he autonomously chooses to engage in physician‐assisted suicide (PAS) or voluntary active euthanasia (VAE). Some of us are unsure whether he or his physician would be acting rightly in ending his life. One basis for such doubt is the notion that persons have dignity in a Kantian sense. This paper probes responses that David Velleman and Frances Kamm have suggested to the question of whether participating in PAS or VAE to benefit oneself, as the young man might, respects the dignity of persons, specified in an orthodox Kantian way. Velleman claims that it does not, while Kamm insists that, in certain circumstances, it does. I argue against Kamm's position. I go on to contend that while orthodox Kantianism might provide a basis for moral concern regarding the case of the young quadriplegic, it suffers from two serious shortcomings. First, it implies that terminally ill patients are wrong to request VAE or engage in PAS to avoid intense suffering, at least when this suffering has not yet overwhelmed their reason. Second, orthodox Kantianism implies that it is wrong for physicians to withdraw such patients from life‐sustaining treatments, even if they request it. To remedy these shortcomings, I sketch an unorthodox Kantian account of respect for the dignity of persons. This account promises to capture the idea that it would be morally problematic for doctors to help the young quadriplegic to die, but to avoid the shortcomings of an orthodox Kantian account.