A report from Poland: treatment and non-treatment of defective newborns

The author and his colleagues surveyed pediatricians in Warsaw, Poland, to determine the doctors' attitudes toward treating infants with severe handicaps. They used a questionnaire originally designed by Australian researchers to survey pediatricians and compared their findings with those of the Australian study. Szawarski notes important differences between the approaches of Australian and Polish doctors to the treatment of handicapped newborns. Polish physicians tend to display an unconditional respect for life, a paternalistic attitude toward decision making, and an unwillingness to distinguish between ordinary and extraordinary means of prolonging life. Half the Polish respondents would be willing to preserve the lives of severely handicapped infants at all costs. Szawarski discusses six factors that may help to explain why Polish physicians have a different approach from that of their Western colleagues to the question of selective treatment of handicapped newborns.     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

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.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. 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: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

Legalized MD-assisted suicide needed to improve care,physician tells right-to-die group

Advocates of euthanasia say clear rules outlining procedures to follow when a terminally ill patient requests assisted suicide would help doctors provide better care without fear of legal or professional recrimination. The Canadian-born medical director of a US-based right-to die organization made the comments during the recent annual meeting of Dying With Dignity, a Canadian group.     

Euthanasia.

The principles of self-determination and individual well-being support the use of voluntary euthanasia by those who do not have moral or professional objections to it. Opponents of this posture cite the ethical wrongness of the act itself and the folly of any public or legal policy permitting euthanasia. Positive consequences of making euthanasia legally permissible respect the autonomy of competent patients desiring it, expand the population of patients who can choose the option, and release the dying patient from otherwise prolonged suffering and agony. Potentially bad consequences of permitting euthanasia include the undermining of the "moral center" of medicine by allowing physicians to kill, the weakening of society's commitment to provide optimal care for dying patients, and, of greatest concern, the "slippery slope" argument. The evaluation of the arguments leads to support for euthanasia, with its performance not incompatible with a physician's professional commitment.     

Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.     

Euthanasia and cryothanasia

In this article we discuss the moral and legal aspects of causing the death of a terminal patient in the hope of extending their life in the future. We call this theoretical procedure cryothanasia. We argue that administering cryothanasia is ethically different from administering euthanasia. Consequently, objections to euthanasia should not apply to cryothanasia, and cryothanasia could also be considered a legal option where euthanasia is illegal.     

Influence of the "Rijeka model" of bioethics education on attitudes of medical students towards death and dying--a cross sectional study

The aim of this study was to assess attitude towards euthanasia, and the influence of socio-demographic data and death education carried out through the "Rijeka model" of bioethics education for the first-year medical students of the School of Medicine, University of Rijeka, Croatia. The cross-sectional study was conducted in the academic year 20031 2004. 124 (61% female) participants were surveyed by using an anonymous questionnaire before and after training. Catholics (p = 0.003) and students from areas with populations of less than 50,000 inhabitants (p = 0.001) had significantly negative attitude towards euthanasia than others before the course, yet no differences were found following this training. Attitude towards euthanasia was significantly positive after the course (p = 0.005). All items in the questionnaire, except "Croatia should legalise euthanasia", received more positive scores after the course. Death education carried through the "Rijeka model" of bioethics education has changed attitudes of medical students towards a more positive perception of euthanasia.     

MORAL FICTIONS AND MEDICAL ETHICS

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life‐sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life‐sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life‐sustaining treatment in order to bring accepted end‐of‐life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end‐of‐life decisions is radically mistaken.     

Non‐verbal interaction of Anglo‐Canadian,Jewish‐Canadian,and French‐Canadian physicians with their young,middle‐aged,and elderly patients

This study investigates the role that non‐verbal communication plays in establishing and maintaining rapport among physicians and their young, middle‐aged, and elderly patients.

Eleven physicians with a variety of patients were studied in the project in Montreal. Five physicians were Anglo‐Canadian, three were respectively Jewish‐Canadian and French‐Canadian. Three additional physicians were part of a pilot project.

Patient‐doctor interviews were videotaped by means of a stationary camera fitted with a wide‐angle lens placed in the doctors’ offices. Physical examinations were not videotaped. After each session, patients filled out a questionnaire elucidating the success of the interview.     

ATTITUDES TOWARDS EUTHANASIA AND ASSISTED SUICIDE: A COMPARISON BETWEEN PSYCHIATRISTS AND OTHER PHYSICIANS

Euthanasia and physician assisted‐suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician‐assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.     

ECS结合情景模拟教学在社区医师急救技能培训中的应用效果分析

目的：探讨应用急救模拟人（Emergency Care Simulator,ECS）结合情景模拟教学法对社区医师进行急救技能培训的效果。方法：应用ECS结合情景模拟对27名社区医师按照2010年美国心肺复苏指南标准进行急救技能培训,急救技能内容包括心肺复苏,气管插管和4项技术（止血、包扎、固定、转运）,比较培训前后成绩的区别;调查社区医师对ECS结合情景模拟教学法的认可程度。结果：社区医师胸外按压培训前后的成绩分别为59．61±12．35和81．42±13．26（P〈0．05）,气管插管的成绩分别为64．18±15．21和85．49±18．17（P〈0．05）,4项技术的成绩分别为62．15±12．28和89．32±15．34（P〈0．05）;96．2％认为该教学方法可以提高学习兴趣和团队合作精神。结论：应用ECS结合情景教学对社区医师进行培训可以提高急救技能,有利于培养团队精神和临床思维能力。     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association''s activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Bioethics and Political Ideology: The Case of Active Voluntary Euthanasia

In different countries responses to important bioethical issues are different, as exemplified by the attitudes towards the voluntary and active forms of medical euthanasia. But why is this the case? My suggestion is that the roots of the variety are, to a considerable degree, ideological.
The most important present-day political ideologies all have their roots in the prevailing doctrines of moral and social philosophy. In the paper these doctrines are outlined and the predicted response towards active voluntary euthanasia within each model is sketched. The conclusion reached is that while it would in some countries be dangerous to allow euthanasia in the prevailing circumstances, the solution is not to hinder the legalization process but to alter the circumstances.     

Bioethics and political ideology: the case of active voluntary euthanasia

In different countries responses to important bioethical issues are different, as exemplified by the attitudes towards the voluntary and active forms of medical euthanasia. But why is this the case? My suggestion is that the roots of the variety are, to be considerable degree, ideological. The most important present-day political ideologies all have their roots in the prevailing doctrines of moral and social philosophy. In the paper these doctrines are outlined and the predicted response towards active voluntary euthanasia within each model is sketched. The conclusion reached is that while it would in some countries be dangerous to allow euthanasia in the prevailing circumstances, the solution is not to hinder the legalization process but to alter the circumstances.     

Childproof caps open Pandora's box

This fall Ontario braced for possible strikes by public servants and teachers. A year earlier, the province''s physicians were preparing their own job action. Walkouts by physicians, which have not been uncommon since the introduction of medicare, create two camps. In one are physicians who say legal job actions are ethical and often improve health care for patients. In the other are some doctors and ethicists who question whether doctors have an ethical right to withdraw services, even if it is legal to do so. Nicole Baer interviewed members of both camps.     

Norwegian Physicians' Knowledge of and Opinions about Evidence-Based Medicine: Cross-Sectional Study

Objective

To answer five research questions: Do Norwegian physicians know about the three important aspects of EBM? Do they use EBM methods in their clinical practice? What are their attitudes towards EBM? Has EBM in their opinion changed medical practice during the last 10 years? Do they use EBM based information sources?

Design

Cross sectional survey in 2006.

Setting

Norway.

Participants

966 doctors who responded to a questionnaire (70% response rate).

Results

In total 87% of the physicians mentioned the use of randomised clinical trials as a key aspect of EBM, while 53% of them mentioned use of clinical expertise and only 19% patients'' values. 40% of the respondents reported that their practice had always been evidence-based. Many respondents experienced difficulties in using EBM principles in their clinical practice because of lack of time and difficulties in searching EBM based literature. 80% agreed that EBM helps physicians towards better practice and 52% that it improves patients'' health. As reasons for changes in medical practice 86% of respondents mentioned medical progress, but only 39% EBM.

Conclusions

The results of the study indicate that Norwegian physicians have a limited knowledge of the key aspects of EBM but a positive attitude towards the concept. They had limited experience in the practice of EBM and were rather indifferent to the impact of EBM on medical practice. For solving a patient problem, physicians would rather consult a colleague than searching evidence based resources such as the Cochrane Library.     

On euthanasia: exploring psychological meaning and attitudes in a sample of Mexican physicians and medical students

Euthanasia has become the subject of ethical and political debate in many countries including Mexico. Since many physicians are deeply concerned about euthanasia, due to their crucial participation in its decision and implementation, it is important to know the psychological meaning that the term 'euthanasia' has for them, as well as their attitudes toward this practice. This study explores psychological meaning and attitudes toward euthanasia in 546 Mexican subjects, either medical students or physicians, who were divided into three groups: a) beginning students, b) advanced students, and c) physicians. We used the semantic networks technique, which analyzed the words the participants associated with the term 'euthanasia'. Positive psychological meaning, as well as positive attitudes, prevailed among advanced students and physicians when defining euthanasia, whereas both positive and negative psychological meaning together with more ambivalent attitudes toward euthanasia predominated in beginning students. The findings are discussed in the context of a current debate on a bill proposing active euthanasia in Mexico City.