Le programme canadien d’aide médicale à mourir (AMM), qui repose sur une législation ambitieuse et des règlements détaillés, n’a pas réussi à fournir aux Canadiens suffisamment de preuves accessibles au public pour montrer qu’il fonctionne comme le prévoit les exigences de la loi, les règlements et les attentes de toutes les parties prenantes. La loi fédérale qui a été adoptée en 2016 a défini les critères d’éligibilité et mis en place un certain nombre de garanties qui devaient être (...) satisfaites avant de fournir une aide à mourir à une personne afin de ne pas transgresser le droit pénal. La responsabilité du contrôle du respect des critères d’éligibilité et des garanties procédurales a été confiée par le ministère fédéral de la santé (responsable de l’ensemble du contrôle) aux gouvernements provinciaux et territoriaux. Certains gouvernements ont publié des données statistiques concernant le programme, mais aucun n’a encore publié un rapport complet sur le respect des critères d’éligibilité et des garanties, comme l’exigent la loi et les règlements. Cet article explique le processus, explore les raisons possibles de cette lacune et propose quelques suggestions d’actions qui pourraient rectifier cet aspect du programme d’AMM. La responsabilité et la transparence font partie intégrante de la mise en oeuvre du programme d’AMM et les publications des rapports de suivi fédéraux et provinciaux/territoriaux obligatoires constituent une approche importante pour obtenir la confiance dans le programme. (shrink)

La mort assistée par un prestataire est en passe de devenir l’une des principales causes de décès au Canada depuis l’adoption de la loi sur l’aide médicale à mourir (AMM) en 2016. Ce qui devait être exceptionnel est devenu courant; certains demandent qu’on s’y attende. De plus en plus de patients atteints de maladies chroniques non terminales sont euthanasiés. Le personnel de santé approuve et propose désormais des MAiD aux patients vulnérables qui sont dépressifs, handicapés, atteints d’une maladie (...) chronique ou appauvris. Cet article présente une justification du point de vue de la loi morale transcendante, traditionnellement appelée loi naturelle, pour expliquer pourquoi le Canada a maintenant le régime d’euthanasie le plus libéral au monde. L’acte d’euthanasie exige que le prestataire mette délibérément fin à la vie du patient en lui administrant une substance mortelle. Cette pratique est contraire à la loi morale transcendante : ne pas tuer. Dès lors qu’une culture rejette délibérément cette loi fondamentale et adopte une éthique utilitaire dépourvue de tout principe, à l’exception de la notion d’autonomie, il est inévitable que cette pratique entraîne une ambiguïté et une incertitude éthique. Au fur et à mesure que la pratique persiste et devient la norme, l’aveuglement moral se développe et conduit à des abus flagrants sur les êtres humains. Je présente un diagramme éthique, la courbe de dissociation morale, qui illustre la raison des tendances observées au Canada. Le système de santé canadien doit réaffirmer les principes de l’éthique hippocratique et la dignité inhérente de ses patients. Les professionnels de la santé doivent donner la priorité aux soins palliatifs de haute qualité, empreints de compassion, et dire « non » à l’idée de mettre délibérément fin à la vie de patients souffrants. Ce faisant, la clarté morale sera retrouvée et les plus vulnérables de la société seront protégés. (shrink)

La récente modification de la loi canadienne permettant l’accès à l’aide médicale à mourir en restreint l’admissibilité, entre autres critères, à ceux pour qui « la mort naturelle est devenue raisonnablement prévisible ». Une révision récente de certains aspects de la loi a examiné les preuves concernant l’accès à l’aide médicale à mourir dans trois situations de refus : demandes de mineurs matures, demandes anticipées et demandes pour lesquelles la maladie mentale est la seule condition (...) class='Hi'>médicale sous-jacente [1]. L’exigence de cet examen a été incluse dans la loi qui a introduit l’aide médicale à mourir au Canada. Tant le changement initial de la loi que l’examen lui-même négligent la prise en compte de ceux qui ont des souffrances intolérables, et pour lesquels la mort naturelle n’est pas raisonnablement prévisible. Cet article explore la possibilité d’étendre l’accès à l’aide médicale à mourir en supprimant ce critère limitatif. Il considère également les défis éthiques que cela peut présenter pour ceux qui travaillent en réhabilitation. (shrink)

À la lumière de la législation actuelle sur l’aide médicale à mourir (AMM; aussi appelée euthanasie et suicide assisté) dans différents pays du monde, certains arguments ont été consacrés au droit à l’objection de conscience pour les professionnels de la santé dans ces pratiques spécifiques. Les objectifs de cette étude exploratoire sont de fournir une vue d’ensemble des motivations et des causes qui se cachent derrière l’objection de conscience identifiée par la littérature précédente selon les expériences (...) des professionnels et de vérifier si ces motivations correspondent aux débats théoriques sur l’objection de conscience. Comme le montrent les résultats, il existe une dissonance entre les motivations incluses dans la définition traditionnelle et courante de l’objection de conscience utilisée dans les cadre théoriques et spéculatifs et les facteurs réels que les études empiriques relèvent comme motivations déclarées pour s’opposer à l’AMM. Par conséquent, soit nous envisageons de nouveaux facteurs à inclure dans les causes de la “conscience”, soit nous acceptons qu’il existe des motivations qui ne sont pas réellement applicables à l’objection de conscience et qui devraient être traitées par d’autres moyens. L’objection de conscience à l’AMM étant multiforme, il peut y avoir différents types de motivations qui agissent en même temps. Il est donc pertinent de rééquilibrer les considérations théoriques et empiriques pour bien comprendre la complexité du phénomène et ainsi donner des pistes sur la meilleure façon de traiter l’objection de conscience. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness as the (...) sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-me dical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.67695 04. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

Commentary on the film, Tout s’est bien passé, by François Ozon, which tells the story of a person who wants to exercise his wish to die in the context of assisted suicide/euthanasia. The action takes place in France and shows the impact on the relatives.

We recently conducted a Quebec-wide postal survey designed to assess major stakeholders’ attitudes toward extending medical assistance in dying (MAiD) to non-competent patients with dementia. This paper reports the results of qualitative analyses of the comments left by the respondents at the end of the questionnaire. The questionnaire was mailed to randomly selected representatives of four stakeholder groups: adults 65 years old and over (n=621), informal caregivers of persons with dementia (n=471), nurses (n=514) and physicians (n=653) caring for such patients (...) at the time of the survey. A total of 1,050 questionnaires were returned, of which 420 included comments. Comments were coded into categories, themes and subthemes, and the frequency of categories compared across the four stakeholder groups. Coding enabled identification of 23 themes and five sub-themes clustered into seven major thematic categories. These relate to: 1) the respondent, 2) the survey and questionnaire, 3) persons with dementia, 4) their informal caregivers, 5) the healthcare system, 6) the legal framework governing end-of-life care, and 7) society in general. These categories were identified in all stakeholder groups, although to a varying degree for five of the seven categories. This study highlights the host of factors that may influence a person’s attitude toward extending MAiD to non-competent patients with dementia. It also illustrates how making systematic use of free-text comments can provide valuable insight into attitudes toward complex social policy issues and extend understanding of postal survey findings. (shrink)

The introduction of medical assistance in dying (MAID) in Quebec and Canada raises the question of extending this service to minors. The constant presence of nurses at the patient’s bedside leads them to receive requests related to MAID. The aim of this study is to explore the perceptions of nurses working in paediatric oncology services concerning the possibility for adolescents over 14 years of age requesting MAID. Six nurses working in paediatric oncology or palliative care or in direct contact with (...) adolescents at the end of their lives as part of their nursing work took part in an individual semi-directed interview. The results of this research highlight that: 1) nurses recognise their supportive role in the care of patients at the end of life; 2) most have a professional opinion in favour of the MAID for adults and distinguish this from their personal opinion; 3) they value the discussions around the MAID and are concerned about the establishment of criteria for it; and 4) long experience as a nurse leads to more concerns about the expansion of the MAID, but at the same time makes nurses more comfortable providing information about this subject. In light of these findings, academic and paediatric health care institutions need to recognise and evaluate the need for training nurses on MAID to better equip them to deal with such situations and thus better meet the needs of their patients. (shrink)

Que signifie autoriser le suicide assisté et l'euthanasie? Et avec quelles conséquences? Quelles sont les responsabilités humaines, politiques et soignantes engagées à l'égard de la personne vulnérable atteinte d'une maladie incurable, en situation de handicap ou de grande dépendance, voire éprouvant une souffrance qui lui est insupportable? L'accompagnement relèvera-t-il alternativement du libre choix de la personne entre soins palliatifs ou aide médicale à mourir? Au regard des pays ayant déjà légiféré dans ce domaine, quelle certitude a-t-on que le (...) 'modèle français' d'assistance active à mourir sera soumis à des critères d'encadrement strictement appliqués? En quoi ce choix de société engage-t-il les valeurs de notre démocratie? C'est à toutes ces questions que répond en spécialiste Emmanuel Hirsch, en démontrant que soigner par la mort n'est plus un soin. Un ouvrage indispensable pour saisir les enjeux du débat actuel et mesurer les conséquences potentielles d'une législation sur la fin de vie pour les droits fondamentaux de la personne."--Page 4 of cover. (shrink)

L’assistance médicale à mourir (AMM) a reçu beaucoup d’attention de la part de nombreux acteurs dans le domaine de la bioéthique. Des philosophes, des théologiens, des avocats et des cliniciens de toutes sortes ont abordé de nombreux aspects difficiles de cette question. Le débat public, la politique publique et la loi ont été renforcés par des analyses disciplinaires variées. Avec la légalisation du AMM au Canada, on s’intéresse maintenant à des questions qui ont toujours été éclipsées par le débat (...) sur l’autorisation de l’AMM. Un de ces problèmes est l’arrêt volontaire de manger et boire (AVMB) comme une alternative à l’AMM. Dans cet article, je vais appliquer une perspective légale à la question. Une compréhension des aspects légaux de l’AVMB permet d'établir les fondements d'une réflexion éthique au sujet de son autorisation. Est-il permis pour ceux qui préfèrent l’AVMB à l’AMM? Est-il permis pour ceux qui ne sont pas admissibles à l’AMM en vertu de notre législation actuelle – pour ceux qui n’ont pas de maladie grave et irrémédiable, pour les mineurs matures, pour les personnes dont la seule condition médicale sous-jacente est un trouble mental et qui ne rencontrent pas les critères d’admissibilité, et pour les personnes ayant perdu leur capacité, mais ayant rempli une directive préalable? (shrink)

De nos jours, les sociétés mandatent fortement la médecine, par des législations variées – sédation, euthanasie, aide médicale à mourir –, pour construire la fin de vie d'autrui à sa demande. L'éthique se trouve de plus en plus sollicitée dans les pratiques soignantes. Mais quelle éthique? Une accumulation de principes? Une éthique réduite à la seule normativité juridique, à un protocole? S'efforçant de réfléchir à quoi se trouvent aujourd'hui confrontés les professionnels s'ils deviennent, dans les faits, les "gardiens" (...) du sens de l'existence de celui, celle qui n'en peut plus, peut-on se contenter de la seule raison pour déployer la signification d'une action? S'il importe de rendre compte en raison des motifs d'une décision, d'un acte, ces derniers s'inscrivent aussi dans un registre plus large, celui de la spiritualité. C'est la voie qu'explore cet ouvrage : comment faire habiter ensemble l'éthique et la spiritualité pour penser la demande et les modalités de réponse à la construction contemporaine du mourir? (shrink)

Il semble que la mise en oeuvre des droits reconnus par les législateurs et les tribunaux en contexte d’avortement tardif et d’aide médicale à mourir connaît, en pratique, un problème d’effectuation. En effet, nous nous trouvons actuellement dans une ère où le droit accorde énormément d’importance à l’autonomie individuelle dans le domaine médical, mais où les pratiques et les autres normativités viennent considérablement limiter cette autonomie. Il convient, dès lors, de poser un regard critique sur le concept d’autonomie (...) en contexte d’avortement tardif et d’aide médicale à mourir. Ces constats soulèvent des questionnements sur le rôle et les limites du droit étatique lorsque transposé en contexte clinique, ainsi que sur le peu d’attention que porte le droit aux destinataires de la norme. Le défi consiste alors à faire cohabiter les différentes normes et valeurs afin que les mécanismes de prises de décisions traduisent un souci réel d’assurer le vivre ensemble. (shrink)

Context: Since 2015, physicians are the only health professionals who have the legal authority to administer medical aid in dying (MAID) in Quebec. A new legislative context is bringing major changes to their end-of-life care practice. Objective: Explore the meaning-making factors that emerge from the experience of physicians administering MAID in order to shed light on what leads them to integrate this practice into their professional continuum. Methodology: Semi-structured interviews were conducted with ten physicians who had performed at least one (...) MAID throughout the territory of the CIUSSS de l’Estrie. Analysis: Conducted using Pierre Paillé’s (1994) grounded theorization, it showed that MAID is a human approach requiring time and social skills, and where life skills are paramount. The results suggest that MAID is located at the boundaries of the physician’s personal and professional identity. In short, what motivates a physician to participate in the MAID process is their narrative identity, including the values and meaning that they give to their experiential journey. Conclusion: MAID is an existential form of care, and the process is experienced differently by each physician; therefore, it is important to respect the meaning and values of each physician, whether or not they incorporate MAID into their medical practice. (shrink)

L’aide médicale à mourir (AMM) devrait être légalisée au Canada à partir de mars 2024 pour les personnes dont la seule condition médicale sous-jacente est un trouble ou une maladie mentale (AMM MM-SCMS). Dans le cadre de l’élaboration de lignes directrices visant à assurer la sécurité et la cohérence de l’AMM MM-SCMS, il convient d’accorder une attention suffisante à l’interprétation de la terminologie ambiguë de la législation actuelle et de veiller à ce que ces interprétations soient fondées (...) sur des principes éthiques acceptables. (shrink)

En 1994, Sue Rodriguez se suicide avec l’aide d’un médecin après une intense bataille judiciaire en Cour suprême du Canada dont l’objet était la décriminalisation du suicide assisté. À la suite de ce suicide, aucune accusation criminelle ne fut portée contre la ou les personnes ayant présumément aidé Sue Rodrigues à mettre fin à ses jours, et ce malgré le fait que le suicide assisté est un acte criminel au Canada. Cette non-intervention du (...) droit pénal est examinée en fonction du rôle que l’affaire Rodriguez a pu jouer dans la transformation des moralités au Canada. Dans ce livre, le suicide assisté de Sue Rodriguez est envisagé comme un « crime » utile (au sens durkheimien du terme), car il met en évidence une inconsistance entre les moralités dominantes inscrites dans le droit pénal et les conditions sociales qui ont rendu ce « crime » possible. Apparenté au crime de Socrate, le « crime » de Sue Rodriguez est analysé comme un héraut annonciateur de nouvelles moralités, comme un prélude préparant directement la voie à des changements dans le poids accordé aux moralités dominantes. Dans ce contexte, le rôle du droit pénal comme mode privilégié de régulation morale est remis en question. (shrink)

« Un soin inédit fait nouvellement partie de l’arsenal thérapeutique de la médecine occidentale. Presque un oxymore, l’aide médicale à mourir ne fait pas l’unanimité. Or, une nouvelle frontière est sur le point d’être transgressée. Parce que certains font l’erreur de considérer la perte de dignité comme possible, ils mettent de l’avant la mort comme le remède ultime aux souffrances des gens atteints de démence. On oublie alors que cette sensation de déchéance peut être soignée autrement. De plus, (...) nous démontrons que la défense de l’autonomie ne saurait justifier l’euthanasie en démence. Notre manifeste confirme également l’importance d’en finir avec la peur du centre d’hébergement et de soins de longue durée (CHSLD). Ainsi, la fragilité de l’aîné souffrant de démence doit être célébrée en tant que richesse oubliée pour promouvoir une telle modification des mœurs au sein des établissements en cause. Notre réflexion contre l’euthanasie en démence, appuyée par de nombreux cliniciens, contribue à la protection des aînés vulnérables. »--. (shrink)

Une personne compétente peut-elle refuser des soins afin de rendre son décès naturel raisonnablement prévisible pour être admissible à l’aide médicale à mourir (AMM)? Prenons l’exemple d’un patient compétent atteint d’une paralysie du côté gauche à la suite d’un accident vasculaire cérébral droit qui ne devrait pas mourir avant de nombreuses années ; normalement, la cause de son décès ne serait pas prévisible. Cependant, il refuse de se retourner régulièrement, de sorte que son médecin peut prédire que des (...) plaies de pression se développeront, entraînant une infection pour laquelle il refusera le traitement et mourra par conséquent. Est-il maintenant admissible à l’AMM? Prenons l’exemple d’un patient compétent atteint d’une sténose spinale (affection non mortelle) qui refuse de manger (mais pas de boire pour ne pas perdre sa capacité à cause de la déshydratation). Par conséquent, son médecin peut prédire la mort par famine. Est-elle maintenant admissible à l’AMM? Pour répondre à ces questions, nous devons répondre à trois sous-questions : 1) les patients compétents ont-ils le droit de refuser des soins ; 2) les prestataires de soins de santé ont-ils l’obligation de respecter ces refus ; et 3) les décès résultant de refus de soins sont-ils naturels aux fins de déterminer si un patient est admissible à l’AMM? Si un patient compétent a le droit de refuser certains soins particuliers et que les prestataires de soins de santé ont l’obligation de respecter ce refus, et si le décès qui résulterait du refus de ces soins est naturel, alors ce refus de soins est une voie légale vers le AMM. Toutefois, si le patient compétent n’a pas le droit de refuser certains soins particuliers, ou si les prestataires de soins de santé n’ont pas l’obligation de respecter ce refus, ou si le décès qui résulterait du refus de ces soins n’est pas naturel, alors ce refus de soins ne constitue pas une voie légale vers le AMM. Dans cet article, nous explorons ce terrain juridique complexe avec les implications éthiques les plus profondes : l’accès à l’AMM. (shrink)

Demander une assistance médicale à la procréation, recourir à l'avortement pour des raisons diverses, contrôler après coup une conduite sexuelle à risque par une pilule du lendemain, et bientôt peut-être exiger d'être euthanasié : depuis que l'État s'est engagé dans un processus de dépénalisation de ces pratiques médicales, on peut aujourd'hui faire beaucoup de choses de son propre corps quand il s'agit du début ou de la fin de vie. Cette liberté s'exerce néanmoins à une condition, toujours la même (...) : se présenter devant un médecin. Et que vous demande ce médecin? Presque rien, semble-t-il. Il vous demande de vous asseoir et de parler de votre état, de votre demande. Bref, de ce qui vous amène là. C'est ce " presque rien " dont il est question dans cet ouvrage. Un " presque rien " qui révèle, en réalité, un nouveau système de surveillance dans lequel le médecin prodigue informations et conseils à un sujet jugé désormais capable de prendre seul des décisions souveraines en matière de vie et de mort. Un face-à-face où apparaît le malaise de ceux qui assument la délicate mission de recueillir l'expression du désir ou de la détresse. À partir d'une longue enquête dans le secret des cabinets médicaux, l'auteur explique comment la régulation juridique a laissé place à des formes de pouvoir beaucoup plus sophistiquées, un dispositif souple de gouvernement des conduites qui laisse toute sa place à l'autocontrôle et à l'intériorisation par les individus des normes sociales. Elle montre ainsi comment, du cabinet du praticien jusqu'au Comité consultatif national d'éthique, c'est une nouvelle administration du vivant qui se met en place. (shrink)

The author maintains that the liberal argument advanced by Dworkin et al. implies a more general moral right, one that is not restricted to people in their terminal phase. The author then discusses Velleman's claim that this argument is subject to the following incoherence: invoking the idea that death is a benefit for a person implies that the person in question is endowed with a value that death would destroy. The author shows that the apparent plausibility of this counterargument is (...) due to a confusion between different evaluative concepts. (shrink)

Background Some have hypothesized that changing attitudes toward medical aid in dying (MAID) contribute to increased suicide rates, perhaps by increasing interest in dying or the perceived acceptability of suicide. This would represent a strong criticism of MAID policies. We sought to evaluate the association between the legalization and implementation of MAID across the U.S. and changing suicide rates.Methods We evaluated state-level monthly suicide death rates from 1995 to 2021. Because suicide rates vary by state, (...) we constructed geographically-weighted regression models controlling for annualized state-level sociodemographic factors, such as racial distribution (percent Caucasian), average age, income levels, unemployment rates, rates of spiritual engagement, firearm ownership rates, gender ratios, and education levels. We applied a difference-in-difference analysis within our geographically-weighted models.Results 927,929 Suicide deaths were represented in the study. Ten states and the District of Columbia had legalized MAID within the study period. In an univariable analysis, states that legalized MAID differed significantly from non-MAID states with respect to mean monthly suicide rate (non-MAID States: 1.46; MAID states: 1.78; p < 0.0001), as well as several covariates. Monthly suicide death rates were spatially autocorrelated (Moran’s I = 0.607, p < 0.0001). In separate geographically-weighted difference-in-difference analyses, changes in suicide rates were not significantly associated with MAID legalization (β = 0.042, p = 0.33) or with later MAID implementation (β = 0.030, p = 0.63), with differences in suicide rates in MAID and non-MAID states being attributable to baseline between-state differences.Conclusions Our study failed to find evidence that suicide rates were positively associated with MAID legalization or MAID implementation, when controlling for geographic variation and multiple sociodemographic factors associated with suicide risk. This finding contrasts with other studies that have reported a positive association between suicide rates and MAID, and so calls into question one argument against MAID legalization. (shrink)

The entry into force in Quebec of the law regulating medical assistance in dying seems to have revived discussions on the concept of conscientious objection (CO) among health professionals. In order to better understand this concept, an integrative review of 39 articles, both national and international, was carried out. To be considered for this review, the articles had to include a definition of CO and at least one criterion justifying its acceptability, or not, in the Western context of care. A (...) theoretical representation of the data extracted from the articles was developed by an inductive thematic process. This representation, which illustrates CO and its criteria of acceptability in the health field, is articulated in relation to four interconnected poles. Two of these poles, care and professional competence, underlie the very definition of CO since without one or the other, the latter cannot exist. The other two poles, collective and individual, convey the values and powers involved when it comes to CO in a healthcare context. The interaction between these four poles illustrates the criteria of acceptability or non-acceptability of CO. This representation of CO thus makes possible a dynamic view of CO and has the advantage of being adaptable to various types and contexts of care, beyond medical assistance in dying. It also offers a theoretical basis for further exploration of this concept. (shrink)

The debate regarding physician-assisted suicide continues in our society. Despite the recent opinions of the United States Supreme Court, this issue is unlikely to go away anytime soon. For a variety of reasons, this debate is now conducted in the legalistic terms of individual rights and liberties. As a result, perhaps we philosophers have been left behind. This is now a matter for the legal arena and philosophy is likely to be irrelevant. I would like to suggest otherwise for (...) two reasons. (shrink)

The practice whereby terminally ill patients choose to end their own lives painlessly by ingesting a drug prescribed by a physician has commonly been referred to as physician-assisted suicide. There is, however, a strong trend forming that seeks to deny that this act should properly be termed suicide. The purpose of this paper is to examine and reject the view that the term suicide should be abandoned in reference to what has been called physician-assisted suicide. I (...) argue that there are no good conceptual or philosophical reasons to avoid the suicide label. I contend that intending one’s death is essential to the nature of suicide, and this intention is normally required on the part of the terminally ill patient when she knowingly takes a life-ending drug. Additionally, the analysis shows that any plausible strategy that avoids the term suicide is counteracted by the way in which advocates of the practice want to make it legal. (shrink)

Where assistance in suicide is readily available to those dying of AIDS, as in the west coast gay communities of the United States and in the Netherlands, we must examine the different roles of physicians and friends (including lovers, spouses, family members, religious advisors, members of support groups, and intimate others) in helping a person with AIDS decide about and carry out suicide. This paper makes a central assumption: that where assistance in suicide is available, it is (...) the moral obligation of others to protect and enhance as much as possible the rationality of that choice. Four components are identified in a rational choice about suicide in AIDS – whether it is a choice for or against suicide. Phrased as questions a person with AIDS might ask him- or herself, they are: (1) "Is suicide an option I want to consider?" (2) "Shall I hold out for the chance of a cure?" (3) "How shall I time my suicide?" (4) "What weight shall I give to the welfare and interests of others?" Although physicians often make assertions relevant to (1), they are appropriately involved only in (3); and although friends or intimate partners often provide the patient with anecdotal information relevant to (3), they should be involved primarily in (1). In short, both physicians and friends often intervene in the wrong parts of choices made by a person with AIDS about suicide. Keywords: AIDS, assisted suicide, euthanasia, rationality, role of friends and physicians, timing CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Active Euthanasia and Assisted SuicidePat Milmoe McCarrick (bio)Although the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in its 1983 report, Deciding to Forego Life-Sustaining Treatment, described the words and terms "euthanasia," "right to die," and "death with dignity" as slogans or code words—"empty rhetoric," (I, p. 24), the literature reviewed for this Scope Note continues to use these terms. Therefore, to (...) discuss the termination of a patient's life by a physician at the patient's request, the phrase active euthanasia is used, and the supplying of a means by a physician whereby a patient can end his or her life is referred to as assisted suicide.Euthanasia, either as the "good death" from classical Greek or "mercy killing" to end unbearable suffering in the dying, has long been a topic of interest in western civilization (III, Brody 1989). In recent years, public awareness of this discussion about control over the time of one's death has been informed by a series of well-publicized events. They include the November 1991 rejection by a vote of 54 percent to 46 percent of the Washington state Initiative 119, which would have allowed the option of requesting one's physician to "aid-in-dying" for adult patients in a "medically terminal condition" (V, Gross 1991); two medical journal articles describing physician's actions in helping bring death to two patients (V, Anonymous 1988; V, Quill 1991); Dr. Jack Kevorkian's assistance in the suicide of three women (V, Belkin 1990; V, Wilkerson 1991); and the best seller status of a how-to book on committing suicide with opiates obtained from a physician (III, Humphry 1991).For the most part, material included in the annotated bibliography in Scope Note 18 has been chosen from works published in the four years since "It's Over, Debbie" (V, Anonymous 1988) appeared in early January 1988 in the Journal of the American Medical Association.Dr. Edmund D. Pellegrino (V, 1991, pp. 3118-19) presented opposing views about active voluntary euthanasia as follows:Those who favor voluntary euthanasia argue that it is a beneficent and compassionate act; it respects autonomy by preserving the patient's control of the manner, method, [End Page 79] and timing of death; it takes the matter outside the reach of "medical power" (accessed in this Scope Note's bibliography at V, Fletcher 1973; V, Nowell-Smith 1989) and scrupulosity; and it prevents the injustice that allows some patients to choose death by refusal of life-support measures, while denying others the right to do so by active euthanasia....The opponents of active euthanasia argue that it undermines the value of, and respect for, all human life (V, Kass 1989; V, Coyle 1990; V, Singer 1990). They fear that guidelines cannot avoid sliding down the "slippery slope" to involuntary euthanasia and selective devaluation of the lives of the most vulnerable among us.... If euthanasia is legal, it is predicted that patients will feel subtle pressure to conform so as to relieve the economic and emotional burdens they impose on family and friends.Euthanasia, its opponents further argue, is socially destructive: it undermines trust in physicians, desensitizes society to killing, and imperils the ground already gained in legitimating passive euthanasia(IV, Wolf 1989).Physicians were not particularly involved with a patient's death until after World War II when participation grew in proportion to the growth of technology. Since the complex, life-sustaining equipment that could forestall death was located in a hospital, death itself became almost completely medicalized (V, Dagi 1991). For terminally ill persons who would like to die a painless death, either by their own hand or with assistance, physicians have almost a monopoly on obtaining strong drugs for distribution to patients (V, Abrams 1990).Active euthanasia for human beings is not legalized anywhere in the world (V, VonDrehle 1991). It is classified as homicide or murder in all fifty states and in Great Britain, Canada, Australia, and the Phillippines (V, Nerland 1989). Twentysix states in the United States prohibit assisted suicide by statute (V, Rosenblum 1990).In 1969 in the Netherlands, a physician named Jan Hendrik van... (shrink)

When a terminally ill patient kills herself, using a drug prescribed by a physician for this purpose, in bioethical literature this would be described as a case of physician-assisted suicide. This would also be a case of suicide according to the standard account of suicide in the philosophical literature. However, in recent years, some authors have argued that terminally ill self-killing in fact should not be considered suicide. In this paper, we don’t try to address the (...) philosophical merits of such arguments. Instead, we ask whether these considerations align with the way non-philosophers think about suicide. We present empirical evidence from four studies that address different concerns raised about terminally ill self-killing being a suicide. We conclude that the raised concerns cannot be supported by the folk understanding of suicide. (shrink)

Any case raising the profile of ‘assisted-dying’ and public policy naturally causes consternation, excitement, heated debate and concerns from different parties, worried that the law is unclear, unfair, too conservative, too permissive, neglectful of ‘the vulnerable’ or indifferent to the proper scope of freedom for ‘the competent’. It was unsurprising, then, that much attention focused on the litigation between Debbie Purdy and the Director of Public Prosecutions .1–4 Ms Purdy has muscular sclerosis, and would like to be free, at a (...) time of her choosing, to travel to receive assisted suicide in a jurisdiction that permits this. To do so, she will need the help of her husband. In contrast with the famous Pretty case,5 Ms Purdy did not seek a proleptic immunity from prosecution under the Suicide Act 1961. Rather, she invoked her human right to respect for private and family life, and argued that the DPP should publish guidance detailing the basis on which he exercises his discretion to bring a prosecution for the crime of aiding, abetting, counselling or procuring a suicide in England and Wales. Her case, when heard in the House of Lords, was successful. 3A decision to prosecute cases of assisted suicide pivots on the satisfaction of two key issues: the ‘evidential test’—is there sufficient evidence to justify bringing a prosecution?; and the ‘public interest test’—is it in the public interest to bring a prosecution? Rightly or wrongly, the threshold for meeting the evidential test seems to be set very low.6 Focus tends to fall, therefore, on the public interest aspect of the decision. In September 2009, the DPP published interim guidance, which detailed the offence of ‘assisting a …. (shrink)

In this paper I use William James's understanding of significance in life to show that for certain patients euthanasia and assisted suicide can be importantly meaningful acts that family, friends, and health care professionals must acknowledge and even, at times, aid in bringing to fruition. Dying with meaning is transformative. It reshapes the lives of others that are left behind, giving to their lives new groundings by engaging them in the meaning of dying for us. For the patient, dying (...) with meaning takes the seemingly formless void in the abyss of death and gives it a significant purpose in the last stages of life itself; it turns potential nothingness into actual significance. To the extent that we outsiders do not help the dying, we condemn terminally ill patients to a meaningless existence until they die. (shrink)

What I call medically enabled suicides have four distinctive features: 1. They are instigated by actions of a suicidal individual, actions she intends to result in a physiological condition that, absent lifesaving medical interventions, would be otherwise fatal to that individual. 2. These suicides are ‘completed’ due to medical personnel acting in accordance with recognized legal or ethical protocols requiring the withholding or withdrawal of care from patients (e.g., following an approved advance directive). 3. The suicidal individual acts purposefully to (...) ensure that medical personnel will act on these protocols. 4. These suicides do not involve medical personnel providing aid in dying in the standard sense, either through (a) active voluntary euthanasia, or (b) assistance by means of prescriptions, etc. -/- Regardless of how common medically enabled suicides are, they raise compelling questions at the interface of medicine and individual choice. After first clarifying the concept of medically enabled suicide and exploring some of the reasons why it might be attractive to suicidal individuals, I then investigate two apparent dilemmas that medically enabled suicides raise for medical care providers. The first alleges that medical care providers may not contribute to harming their patients, and so they may not contribute to their patients’ suicides. The second alleges that if care providers, as a matter of personal conscience, believe that suicide is wrong, then they may not be compelled to contribute to their patient’s acting wrongly by assenting to the wishes of a patient pursuing medically enabled suicide. Both dilemmas arise from the fact that while medical personnel are bound by widely accepted precepts of medical ethics to honor the competent wishes of their patients, medically enabled suicides entangle them in their patients’ suicidal plans in ways that result in their contributing to those suicides. I conclude that neither dilemma should be resolved in the direction of medical personnel having the right to refrain from involvement in medically enabled suicides. Thus, while we may find medically enabled suicide distasteful or exploitative, a strong case cannot be made that medical personnel refusing to involve themselves in such suicides is ethically permissible. (shrink)

Terminally ill patients in 10 states plus Washington, D.C. have the right to take prescribed medications to end their lives (medical aid in dying). But otherwise-eligible patients with neuromuscular disabilities (ALS and other illnesses) are excluded if they are physically unable to “self-administer” the medications without assistance. This exclusion is incompatible with disability rights laws that mandate assistance to provide equal access to health care. This contradiction between aid-in-dying laws and disability rights laws can force patients and clinicians into violating (...) one or the other, potentially creating an underclass of patients denied medical care that is available to those with other (less physically disabling) terminal illnesses. The immediacy of this issue is demonstrated by a lawsuit in Federal court filed in August 2021, requesting assistance in self-administration for terminally ill patients with neuromuscular diseases. This paper discusses the background of this conflict, the ethical issues at the heart of the dilemma, and recommends potential remedies. (shrink)

Si, depuis quelques dizaines d'années, la médecine de la reproduction s'est considérablement développée pour venir en aide aux couples confrontés à l'impossibilité de concevoir naturellement un enfant, c'est généralement avec l'objectif initial de favoriser une conception avec les gamètes du couple. Le développement successif de l' " Insémination Artificielle " et de la " Fécondation in Vitro " a néanmoins permis dans le même temps de faire émerger différentes possibilités alternatives de conception, en transgressant notamment le principe de la (...) filiation biologique. Un couple peut aujourd'hui concevoir un enfant avec d'autres gamètes que les siens et même envisager l'accueil d'un embryon conçu par un autre couple. Dans ces situations, la question de la conciliation des intérêts des différents acteurs se pose. En optant pour la règle de l'anonymat des dons qui prive l'enfant de toute information sur le donneur, certaines législations semblent considérer que ce principe allie au mieux ces intérêts. Pourtant non seulement la demande croissante de levée de l'anonymat formulée par les enfants issus de l'assistance médicale à la procréation fragilise ce choix de société mais certains pays ont devancé ce voeu en choisissant la transparence génétique. Cet ouvrage est le fruit de riches débats et réflexions échangés entre juristes, médecins, psychanalystes et sociologues, lors du premier Workshop du Réseau Universitaire International de Bioéthique. Adoptant une approche comparative, les articles rassemblés examinent la manière dont sont organisées, dans seize pays de cultures différentes, les pratiques et les conséquences d'un anonymat absolu, relatif, voire inexistant. En dépit d'une diversité de systèmes, un constat unanime ressort : la question de la levée de l'anonymat se pose partout avec acuité. La réponse, elle, réunit ou divise. Mais peut-il en être autrement sur un sujet qui touche aux perceptions sociales de l'identité de la personne, de la filiation ou de la " parentalité "? Créé en 2007, le Réseau Universitaire International de Bioéthique a pour objectif de promouvoir la recherche universitaire en rapprochant des chercheurs, de pays et, de cultures différents, spécialistes des questions liées aux pratiques biomédicales. Partant d'une approche croisée des différents systèmes juridiques, les travaux de ce réseau analysent les choix sociaux en matière biomédicale à travers les prismes de l'éthique, de l'anthropologie, la philosophie ou la sociologie. Ils veulent ainsi contribuer à la réflexion internationale sur la régulation des pratiques biomédicales et, incidemment, sur la conciliation entre les diversités culturelles et un certain universalisme, terreau d'une harmonisation du droit. Cette nouvelle collection sera donc un outil indispensable pour toute personne en quête d'une compréhension des enjeux sociaux de la bioéthique. (shrink)

At the end of 2015, the German parliament passed a new law, entitled "Business-like Suicide Assistance", that effectively ended a rather liberal legal take on assisted suicide in Germany. §217 of the German Criminal Code was based on a proposal drafted by members of the parliament Michael Brand, Kerstin Griese, et all., The drafters’ goal was to prohibit Right-to-Die organisations such as Sterbehilfe Deutschland e.V. as well as repeatedly acting individuals from assisting people in ending their lives. The (...) goal of this article is to outline the new law in broad brushstrokes and raise some concerns. (shrink)

In the last 20 years ‘assisted dying’ (and/or its variants ‘assisted death’, ‘assistance in dying’, ‘aid in dying’) has become increasingly prevalent as a term to denote the intentional ending of the life of a patient by or with the assistance of a doctor. However, there is no agreed definition. This paper focuses on the debate over the definition of this term in the UK. It notes that, broadly speaking, there are two ways in which ‘assisted dying’ has been defined. (...) There are generic definitions, which cover a variety of practices, including self-administration of a lethal drug (assisted suicide) and administration by a healthcare professional (euthanasia) with or without specific eligibility criteria. In contrast, there are stipulative definitions which limit the term to a particular practice, for example, assisted suicide (not euthanasia) of adults (not minors) who are terminally ill (not those with chronic conditions). Examples of the former kind of definition are provided by the British Medical Association in its 2020 members’ survey and the POSTbrief on Assisted dying. Examples of the latter are provided by the British Medical Journal and the British Broadcasting Corporation. This paper argues that stipulative definitions are problematic in that they exclude practices that are widely referred to as ‘assisted dying’. The attempt to restrict the definition leads to the term being used inconsistently. Stipulative definitions can be used consistently if it is acknowledged that they are secondary to the generic sense. This matters because clarity of terminology is a prerequisite of rational debate. (shrink)

Definition of the problem: Attitudes and practice of doctors regarding physician-assisted suicide (PAS) in patients with AIDS became considerably more liberal over the last 15 years in large U.S. cities. However, it remains an open question how the highly active antiretroviral therapies (HAART) have influenced the situation since the late 1990s. Methods and results: In 1999/2000 a nonrepresentative sample of medical doctors, psychologists, social workers, nurses and other health care professionals (n=69) in San Francisco und New York gave semistructured (...) interviews about the present situation of PAS in patients with AIDS. On the basis of written protocols a qualitative evaluation of the expert interviews has been performed. The majority of the health care professionals are familiar with PAS in their professional work. With HAART the requests for PAS in gay patients with AIDS dropped rapidly. PAS has not been noted in other subgroups of patients. However, unsolved problems exist in timing, execution and accompaniment of PAS and in competence assessment of PAS patients. No hints of a slippery slope abuse could be identified in the interviews. Conclusion: Although tolerated, the majority of the doctors still feel uncomfortable with PAS and regard PAS as alien to their professional ethos. In practice PAS takes place on request of a subgroup of AIDS patients only. However, the professional experience with PAS in patients with AIDS has changed the attitude of doctors toward a stronger acceptance of their patients autonomy and partnership with them. Open questions remain regarding the competence assessment of seriously ill and dying patients. (shrink)

Is suicide wrong, profoundly morally wrong? Almost always wrong, but excusable in a few cases? Sometimes morally permissible? Imprudent, but not wrong? Is it sick, a matter of mental illness? Is it a private matter or a largely social one? Could it sometimes be right, or a "noble duty," or even a fundamental human right? Whether it is called "suicide" or not, what role may a person play in the end of his or her own life? This collection (...) of primary sources--the principal texts of ethical interest from major writers in western and nonwestern cultures, from the principal religious traditions, and from oral cultures where observer reports of traditional practices are available, spanning Europe, Asia, the Middle East, Africa, Oceania, the Arctic, and North and South America--facilitates exploration of many controversial practical issues: physician-assisted suicide or aid-in-dying; suicide in social or political protest; self-sacrifice and martyrdom; suicides of honor or loyalty; religious and ritual practices that lead to death, including sati or widow-burning, hara-kiri, and sallekhana, or fasting unto death; and suicide bombings, kamikaze missions, jihad, and other tactical and military suicides. This collection has no interest in taking sides in controversies about the ethics of suicide; rather, rather, it serves to expand the character of these debates, by showing them to be multi-dimensional, a complex and vital part of human ethical thought. (shrink)

In this paper, I address the question of whether it is ever permissible to grant a request for physician-aid-in-dying (PAD) from an individual suffering from treatment-resistant depression. I assume for the sake of argument that PAD is sometimes permissible. There are three requirements for PAD: suffering, prognosis, and competence. First, an individual must be suffering from an illness or injury which is sufficient to cause serious, ongoing hardship. Second, one must have exhausted effective treatment options, and one’s prospects for recovery (...) must be poor. Third, the individual must be judged competent to request PAD. I argue that many cases of treatment-resistant depression meet the first two requirements. Thus, the key question concerns the third. I consider four features of depression that might compromise a person’s decision-making capacity. Ultimately, I conclude that PAD requests from depressed patients can be permissibly granted in some circumstances. (shrink)

Physician aid in dying is a broader topic than euthanasia in that the latter usually refers to active euthanasia, while physician assistance also encompasses the issue of assisted suicide. Volumes could be and have been written on physician-assisted death. But my purpose here is to address a specific aspect of the topic: the policy implications with regard to proposed legislation on physician-aided death.Although the title's reference to physician assistance suggests a focus on the role of the professional, what people (...) often take to be most important and at the heart of the topic is the issue of the patient's rights, usually seen as being manifested in four different ways. First is the right to a dignified death, as free from pain and suffering as possible. In crossing national boundaries and preceding the organization of the professions and the creation of societies, this right is viewed as one that ought to be recognized. (shrink)

Medical aid in dying (MAiD), despite being legal in many jurisdictions, remains controversial ethically. Existing surveys of physicians’ perceptions of MAiD tend to focus on the legal or moral permissibility of MAiD in general. Using a novel sampling strategy, we surveyed physicians likely to have engaged in MAiD-related activities in Colorado to assess their attitudes toward contemporary ethical issues in MAiD.

“Rien n’arrive ni comme on l’espère, ni comme on le craint. Nothing really happens as we hope it will, nor as we fear it will.” 1 Améry appropriates this quote of Proust to highlight how our imaginative powers can never approach its reality during an extreme event. This failure of what he coins our anticipatory imagination is depicted in his phenomenological account of torture, an event whose extremity is later compared to another embodied experience: that of aging. Equating torture with (...) aging may seem shocking to some, and Améry was critiqued for suggesting such a parallel, particularly since he narrates a lived experience with the latter at the mere age of fifty-five. He revisits this critique in the preface to the fourth edition of On Aging: Revolt and Resignation where he states: "Today as much as yesterday I think that society has to undertake everything to relieve old and aging persons of their unpleasant destiny. And at the same time I stick to my position that all high- minded and reverential efforts in this direction, though indeed capable of being somewhat soothing- are still not capable of changing anything fundamental about the tragic hardship of aging." - Jean Améry, On Aging [Améry’s emphasis] The “today” of society that Améry referenced was 1977. But what about today? Is Améry correct in projecting that despite our best efforts nothing fundamental can change the quite unbearable experience of aging? Are attempts to aid the aging complicit in a “vile dupery” that ends in “metaphorically empty” phrases such as “rest in peace”? 3 I would like to pose these questions in the wake of a heated debate in France regarding the legality of assisted suicide for aging persons. Thus, this paper seeks to not only dissect his account of aging but to ask whether his philosophy could be read alongside current French thinkers to better assess comment mourir dans la dignité. (shrink)

In several US states, the legalisation of euthanasia has become a question for voters to decide in public referenda. This democratic approach in politics is consistent with notions of personal autonomy in medicine, but the right of choice does not mean all choices are morally equal. A presumption against the taking of human life is embedded in the formative moral traditions of society; human life does not have absolute value, but we do and should impose a strict burden of justification (...) for exceptions to the presumption, as exemplified by the moral criteria invoked to justify self-defence, capital punishment, or just war. These criteria can illuminate whether another exception should be carved out for doctor-assisted suicide or active euthanasia. It does not seem, in the United States at any rate, that all possible alternatives to affirm the control and dignity of the dying patient and to relieve pain and suffering, short of taking life, have been exhausted. Moreover, the procedural safeguards built into many proposals for legalised euthanasia would likely be undone by the sorry state of the US health care system, with its lack of universal access to care, chronic cost-containment ills, a litigious climate, and socioeconomic barriers to care. There remains, however, common ground in the quest for humane care of the dying. (shrink)

Photo by Hannah Busing on Unsplash INTRODUCTION Religion has long provided guidance that has led to standards reflected in some aspects of medical practices and traditions. The recent bioethical literature addresses numerous new problems posed by advancing medical technology and demonstrates an erosion of standards rooted in religion and long widely accepted as almost axiomatic. In the deep soul-searching that pervades the publications on bioethics, several disturbing and dangerous trends neglect some basic lessons of philosophy, logic, and history. The bioethics (...) discourse on medical aid in dying emphasizes similarity over previously recognized important distinguishing features. For example, it overplays a likeness between assistance in dying and the withdrawal of life-saving technology. In many bioethics’ topics, arguments based on a logical continuum are used to question the lines demarcating important moral differences. l. The Line Between Ethical and Not: Logic Based on Continuum Careful case selection, often either end of a continuum, allows the tearing down or ridiculing of many rules and codes across most professions and fields of interest. This situation holds true for traffic laws as well as medical ethics guidelines. It is relatively simple for those who desire to attack a particular viewpoint by selecting a case that makes that position seem untenable. In the ethics realm, good and bad medicine exist at opposite ends of an ethical continuum, with many practices lying in between. For example, much of medical ethics exists between the Nazi criminal physicians and the most sainted nurse or physician. A gradual progression occurred over less than two decades from a utilitarian position that supported limited euthanasia for those with certain mental illnesses to genocide. German society embraced a utilitarian ethic in which the value of human life no longer was intrinsic but instrumental.[1] Many morally significant points on a continuum were then ignored as the misguided utilitarian policy rampantly continued. A point in the continuum to distinguish between ethically justifiable and that which is not can be difficult to identify compared to the two extremes. This continuum is not unique to ethics but can be applied to almost any other aspect of human life and endeavor. Between a severely ill schizophrenic person and a superbly well-adjusted individual, there is a continuum of mental and psychological function. The existence of a continuum should not paralyze thinking and prevent us from drawing lines and identifying moral differences based on objective criteria as well as moral philosophy. Yet, by focusing on a continuum, many bioethicists use logic to disregard dividing lines between an "ethical" and an "unethical" act. Unfortunately, sometimes bioethicists draw revolutionary conclusions that would change the scope of medical practices which is accepted as ethical. There are many examples of similar shifts on the continuum. Many authors argue for the ethical permissibility of abortion by pointing out that the human fetus is no different in various characteristics, one arguing it is as like an ape or chick as it is like a person,[2] and does not achieve unique human and individual characteristics until well into the first year of life.[3] While human fetuses arguably do not have certain distinctive qualities of personhood, most people shy away from the logical next conclusion: permitting infanticide. For example, Joshua Lederberg condemns infanticide, in the face of biological illogic, because of our emotional commitment to infants, to me, a relatively weak explanation. Sir Francis Crick suggests we might consider birth at two days of life in order to decide whether an infant is a "suitable" member of society.[4] Giublini and Minerva suggest that infanticide should be permissible since late pregnancy abortions are permissible, arguing there is no significant difference between a fetus just before birth and an infant just after birth.[5] Clearly the continuum approach would allow for subjective arguments in favor of later infanticide at other points many days post-birth. Years ago, with a cynical tone, I mentioned infanticide as a further step on the continuum beyond abortion, and I was rightly shouted down as being deliberately provocative to assert the logic would ever stretch so far. While it is not an accepted mainstream position, the movement in academic settings from widespread condemnation to limited possible acceptance of infanticide has taken place in an incredibly short time. Public opinion and medical opinion in these areas have shifted dramatically in a short time. In another area, from a biological and chemical point of view, there is a continuum from man down to a single carbon atom. Yet, it would not seem logical to ignore the emotional differences, the meaning of personhood, or the moral distinction between killing an insect and killing a person. ll. A False Continuum: Medical Aid in Dying I assert that there has been an erosion of ethical guidelines in recent years attributable to using continuums to camouflage important distinctions. James Rachels’ work on active and passive euthanasia, which contends that the two are ethically identical, exemplifies that logic.[6] He illustrates this thesis, using a continuum to compare different scenarios with like consequences as morally equivalent, by comparing the deliberate drowning of a child with a deliberate failure to rescue a drowning child when easily able to do so. The author's comparison proposes that since much of the medical profession has already made peace with withholding treatment in order to hasten death, consistency inexorably demands that we permit active euthanasia as well.[7] When permission for active euthanasia was first introduced, it was limited exclusively to patients suffering severely from an intractable, incurable, and irreversible disease. These guidelines have been continuously eroded. There is now a substantial serious consideration for permitting active euthanasia of healthy elderly individuals who feel that they have completed their lives and are "tired of living."[8] There are many moral and factual differences along the ethical continuum. In human life, there is a difference between a live baby and a fetus, between a viable fetus and one that is not, between a fetus and a zygote, and between a zygote and a sperm cell. Similarly, there is a difference between pulling a trigger to kill someone and not interfering in preventing his death, which is reprehensible though both may be. There is a difference between not resuscitating an 80-year-old man with cancer when his heart stops and injecting him with a fatal dose of potassium chloride. I argue that an overt act of taking life repels civilized human beings is to be commended and encouraged as the reverence for human life or even for just a moment of human life is one of the great contributions of our civilization. CONCLUSION As an orthodox Jew, I feel that divinely inspired guidelines that have stood the test of centuries shape my beliefs, and such guidelines contradict medical aid in dying. I cannot speak to the viewpoint of those who do not access religion in defining their moral stance, nor do I implicate them in the current bioethics' trends, as I am not aware of the personal role of religion in the lives of most such authors. While many nonreligious people have a firm philosophical grounding and oppose medical aid in dying, I suggest that in the absence of any religious or other absolute standards, developing logically defensible ethical guidelines may be challenging. At the least, religion may play a role in defining the points on the continuums that are ethically meaningful and refuting the trending beliefs that if the endpoint is the same, allowing different methods of arriving at that end are somehow ethically equal. The continuum of ways death may result does not negate analysis of whether death is brought about in ways that recognize the importance of life. The German philosopher Hans Jonas said, "It is a question whether without restoring the category of the sacred, the category most thoroughly destroyed by the scientific enlightenment, we can have an ethics able to cope with the extreme powers that we possess today and constantly increase and are compelled to use."[9] While countries vary on the role of religion in policy, with many emphasizing freedoms of religion, a recent position paper released by a group of Jewish, Christian, and Moslem leaders suggested the need for agreement on the unique sanctity of human life.[10] I would recommend that such a document serve as an example of consensus on critical foundational bioethical guidelines for democratic secular societies. - [1] Alexander L Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. A geneticist looks at contraception and abortion, Annals of Internal Medicine 67, sup 2, 25-27. https:/doi.org/10.7326/0003-4819-67-3-25 [3] Ibid. [4] Editorial, Sociology: Logic of biology. Nature 220, 429 https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J Active and passive euthanasia. New England Journal of Medicine 292, 78-80 [7] Ibid. [8] Cohen-Almagor R Euthanizing people who are "tired of life". in Euthanasia and Assisted Suicide-Lessons from Belgium. Ch 11 of Euthanasia and Assisted Suicide, Cambridge University Press pp173-187. 2017 and DOI; https://doi.org/10.1017/9781108182799.012 [9] Hans Jonas, Technology and Responsibility: Reflections on the New Tasks of Ethics, 1972, found as Chapter IX, Philosophical Essays, 1980. https://inters.org/jonas-technology-responsability [10] A position paper of the Abrahamic Monotheistic religions on matters concerning the end-of-life. Vatican Press 28 October 2019 https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2019/10/28/191028f.html. (shrink)

In recent decades, many jurisdictions have moved toward legalizing euthanasia and assisted suicide—together with a growing recognition of the moral right to a medically assisted death. Herewe draw on a comprehensive quantitative review of existing laws on assisted dying, experimental survey evidence, and four decades of time-series data to explore the relationship between these legislative transitions and changing moral attitudes. Our analysis reveals that existing laws on medical aid in dying impose a common set of eligibility restrictions, based on (...) the patient’s age, decision-making capacity, prognosis and the nature of their illness. These eligibility restrictions shape public moral approval of physician-assisted death, equally in countries where euthanasia is legal (i.e., Spain) and illegal (i.e., the United Kingdom). Additionally, records of public attitudes toward euthanasia across numerous countries over a forty-year period uncovered anticipatory growth in moral approval leading up to legalization, but no accelerated growth thereafter. Collectively, our findings suggest that legal frameworks for medical aid in dying crystallize patterns of moral intuition. (shrink)

In 1997, when Oregon became the first U.S. jurisdiction authorizing medical aid in dying (MAID), its law included a requirement that patients be legal residents of the state. Other U.S. jurisdictions legalizing MAID followed Oregon in adopting residency requirements. Recent litigation challenges the legality, as well as the justification, for such requirements. Facing such challenges, Oregon and Vermont eliminated their MAID residency requirements. More states could follow this move, for, in certain circumstances, the U.S. Constitution's privileges and immunities clause protects (...) citizens’ right to travel to secure medical care. Policy considerations could also motivate states to reexamine whether such requirements are justified in light of existing evidence of how MAID laws have been applied. (shrink)

Many bioethicists have recently shifted from using “physician-assisted suicide” (PAS) to “medical aid-in-dying” (MAID) to refer to the act of voluntarily hastening one’s death with the assistance of a medical provider. This shift was made to obscure the practice’s connection to “suicide.” However, as the charge of “suicide” is fundamental to arguments against the practice, “MAID” can only be used by its proponents. The result has been the fragmentation of the bioethical debate. By highlighting the role of (...) human agency—as opposed to natural processes—in causing death, the term “PAS” makes it easier both to perceive potential risks to vulnerable populations and to affirm suicide as a potentially autonomous choice. As such, “PAS” thus more transparently expresses the arguments of both supporters and opponents of the “right to die,” while avoiding the unnecessary stigmatization of suicide and suicidal people which is a result of the usage of “MAID.”. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not ?futile.? Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, ?If this were not an attempted suicide, would a request to withdraw care be reasonable?? We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

RésuméDans cet article, je soutiens que certains patients irrémédiablement dépressifs ont la capacité décisionnelle de consentir au traitement même s'ils veulent mourir. On dit que ces patients ont des déficits de capacité appréciative parce qu'ils manquent de compréhension quant à leur condition. Je soutiens que certains de ces patients acquièrent une telle compréhension s'ils peuvent connaître et articuler une gamme de possibilités futures concernant leur santé. Cet argument nécessite une lentille phénoménologique. La phénoménologie saisit quelque chose de fondamental au sujet (...) de la nature des conditions psychiatriques, comme l'expérience temporelle, qui est sans doute nécessaire pour une évaluation plus approfondie de la capacité requise pour recevoir l'aide médicale à mourir (AMM). (shrink)

Chapter one argues for the important contribution that a natural law based framework can make towards an analysis and assessment of key controversies surrounding the practices of suicide, assisted suicide, and voluntary euthanasia. The second chapter considers a number of historical contributions to the debate. The third chapter takes up the modern context of ideas that have increasingly come to the fore in shaping the 'push' for reform. Particular areas focused upon include the value of human life, the (...) value of personal autonomy, and the rejection of double effect reasoning. Chapter four engages in the task of pointing out structural weakness in utilitarianism and deontology. The thesis argues that major systemic weaknesses in both approaches can be overcome by a teleology of basic human goods. John Finnis' work becomes the underpinning of subsequent applied natural law analysis. Chapter five proceeds to argue for the defence of the intrinsic good of human life from direct attack. The thesis holds out for the proposition "that it is always a serious moral wrong to intentionally kill a human person, whether self or another, regardless of a further appeal to consequences or motive." In support of this, it defends the validity of double effect reasoning as an indispensable part of applied moral decision making. Chapter six critically assesses the arguments of anti-perfectionists that it is not the business of the state to enforce deep or substantive conceptions of the 'good life.' The chapter moves on to argue that the natural law conception of the person in society, centred on the common good, provides a solid framework for assessing both the justification for, as well as the limits on, the role of the state to use its power to legally impose certain moral standards. Chapter seven addresses the concrete relationship between natural law and legal policy by exploring the issue of assisted suicide in the constitutional context of the United States.















. (shrink)

In this paper, I will argue that efforts to legalize aid-in-dying or physician-assisted suicide are attempts to rebrand this sort of death as a good choice. It is common to justify physician-assisted suicide through arguments for a) relieving suffering or b) allowing individual autonomy, but I will show that the problem with these justifications is that once this type of death is judged as acceptable, it is difficult to justify limiting it to a narrow group such as the (...) mentally competent, communicatively able, terminally ill adults designated by these legalization bills. Ultimately, we must either label many more deaths as good deaths, destigmatizing suicide, or we must reject the notion that death at the time we choose is acceptable. I will argue for the latter. (shrink)