Lars Johan Materstvedt

Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force

In 1991, a debate at the European Parliament on euthanasia stimulated discussion at all levels in Europe. Subsequently, the Board of Directors of the EAPC organised a working session together with two experts to help them clarify the position the organisation should adopt towards euthanasia. The experts collaborated with the Board of Directors on a document and in 1994 the EAPC produced a first statement, Regarding euthanasia, published in the official journal of the EAPC – the European Journal of Palliative Care . In February 2001, the EAPC Board asked an expert group to form an Ethics Task Force to review the subject and advise the organisation accordingly.

Attitudes towards, and wishes for, euthanasia in advanced cancer patients at a palliative medicine unit.

Background: Most studies on attitudes towards euthanasia and physician-assisted suicide (PAS) have been conducted in healthy populations. The aim of this study is to explore and describe attitudes towards, and wishes for, euthanasia/PAS in cancer patients with short life expectancy. Method: Semi-structured interviews with 18 cancer patients with a life expectancy of less than nine months. All patients were recruited from an inpatient palliative medicine unit. Results: Patients holding a positive attitude towards euthanasia/PAS do not necessarily want euthanasia/PAS for themselves. Wishes are different from requests for euthanasia/PAS. Fear of future pain and a painful death were the main reasons given for a possible wish for euthanasia/PAS. Worries about minimal quality of life and lack of hope also contributed to such thoughts. Wishes for euthanasia/PAS were hypothetical; they were future oriented and with a prerequisite that intense pain, lack of quality of life and/or hope had to be present. Additionally, wishes were fluctuating and ambivalent. Conclusion: The wish to die in these patients does not seem to be constant. Rather, this wish is more appropriately seen as an ambivalent and fluctuating mental ‘solution’ for the future. Health care providers should be aware of this when responding to utterances regarding euthanasia/PAS.

A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries

Objectives: To analyse legislation and medical professional positions concerning the doctor’s role in assisted dying in western Europe, and to discuss their implications for doctors. Method: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised (Belgium, The Netherlands), or openly practiced (Switzerland), or where it is illegal (Germany, Norway, UK). Results: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide (but not euthanasia) is not illegal in either Germany or Switzerland, but a doctor’s participation in Germany would violate the code of professional medical conduct and might contravene of a doctor’s legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not. Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This “neutral” stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a “medical end-of-life decision” since the 1970s. Conclusion: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions.

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

Background The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD. Methods Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy. Findings All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD. Conclusions This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.

Intention, procedure, outcome and personhood in palliative sedation and euthanasia

Palliative sedation at the end of life has become an important last-resort treatment strategy for managing refractory symptoms as well as a topic of controversy within palliative care. Furthermore, palliative sedation is prominent in the public debate about the possible legalisation of voluntary assisted dying (physician-assisted suicide and euthanasia). This article attempts to demonstrate that palliative sedation is fundamentally different from euthanasia when it comes to intention, procedure, outcome and the status of the person. Nonetheless, palliative sedation in its most radical form of terminal deep sedation parallels euthanasia in one respect: both end the experience of suffering. However, only the latter intentionally ends life and also has this as its goal. There is the danger that deep sedation could bring death forward in time due to particular side effects of the treatment. Still that would, if it happens, not be intended, and accordingly is defensible in view of the doctrine of double effect.

The Euthanasia Debate Palliative care on the 'slippery slope’ towards euthanasia?

The response to our position paper on palliative care and euthanasia i/ 55 commentaries, from 32 countries, in the March 2003 issue of Palliative Medicine i/ has been remarkable in its breadth and variety. Moreover, a most welcome side effect’, as it were, is that many commentators also take the opportunity to provide important information about the development and recent state of palliative care services in their home country as well as giving an overview of the euthanasia debate, or lack of such, in their own context. The reactions are as diverse as there are authors, one could say. Some think we have made a contribution at the conceptual level that will greatly help the debate worldwide as well as in their own country. Others see a contribution that is relevant to clinical practice (the paper `will help our day-to-day practice’, Malas, p. 150). Whilst a further group think our definitions simply mess things up. To illustrate, van der Wal values our contribution concerning concepts and clarity, saying that I am glad that the Task Force suggests, with regard to euthanasia, that the adjectives `voluntary’, `active’ and `passive’ should no longer be used . . . The argumentation is valid. In the spoken and written word this will avoid many unnecessary misunderstandings’ (p. 110). On the other hand, Billings is of the opinion that we have `confused some important definitions and distinctions’ (p. 105). While HaEnninen states: I do not think that the Task Force’s report brings anything new to the discussion’ (p. 166). In other words, to him, we neither make things clearer nor more muddy! Interestingly, support comes both from those who favour the legalisation of euthanasia and from those who oppose that i/ as does attack and rejection of our stance. The EAPC Ethics Task Force‘s reply to critics

Palliative care ethics: The problems of combining palliation and assisted dying

Abstract The performing of euthanasia is now offered as an option by certain palliative care service institutions in Belgium. The approach is known as the ‘integral’ model. Although it is understandable that some physicians are in favour of it, the model is rejected in this article, for both clinical and ethical reasons. Furthermore, the idea of ‘palliative futility’ associated with the model is shown to be incoherent. In countries where assisted dying is legal, palliative care providers should refrain from participating in such practices if they are to remain true to the basic values of such care. The widespread conception that withholding and withdrawing treatment amounts to a ‘hastening’ of death is also rejected.

Attitudes towards assisted dying are influenced by question wording and order: a survey experiment

BackgroundSurveys on attitudes towards assisted dying play an important role in informing public debate, policy and legislation. Unfortunately, surveys are often designed with insufficient attention to framing effects; that is, effects on the respondents’ stated attitudes caused by question wording and context. The purpose of this study was to demonstrate and measure such framing effects.MethodsSurvey experiment in which an eight-question survey on attitudes towards assisted dying was distributed to Norwegian citizens through a web-based panel. Two variations of question wording as well as two variations of question order were employed. Respondents were randomized to receive one of four questionnaire versions.ResultsThree thousand and fifty responses were received. There were moderate to large question wording and question order effects. A majority of Norwegian citizens favour the legalization of assisted dying for patients with terminal or chronic disease.ConclusionsStakeholders in the assisted dying debate need to acknowledge potential framing effects, and accordingly should interpret survey results with caution. The same holds for researchers who conduct attitude surveys in the field of bioethics.

[Medical students' attitudes towards legalisation of euthanasia and physician-assisted suicide].

BACKGROUND We wished to investigate prevailing attitudes among future doctors regarding legalisation of euthanasia and physician-assisted suicide. This issue is important, since any legalisation of these practices would confer a completely new role on doctors. MATERIAL AND METHOD Attitudes were identified with the aid of a questionnaire-based survey among medical students in their 5th and 6th year of study in the four Norwegian medical schools. RESULTS Altogether 531 students responded (59.5% of all students in these cohorts). Of these, 102 (19%) were of the opinion that euthanasia should be legalised in the case of terminal illness, 164 (31%) responded that physician-assisted suicide should be permitted for this indication, while 145 (28%) did not know. A minority of the respondents would permit euthanasia and physician-assisted suicide in other situations. Women and those who reported that religion was important to them were less positive than men to permitting euthanasia or physician-assisted suicide. INTERPRETATION In most of the situations described, the majority of the students in this survey rejected legalisation. Opinions are more divided in the case of terminal illness, since a larger proportion is in favour of legalisation and more respondents are undecided.

Euthanasia: on slippery slopes and vulnerable patients

may take place between patients and professional carers who are not known to each other, in an unfamiliar environment. These discussions may be forced to take place in an acute situation, which is neither helpful nor appropriate for sensible, logical decision making. Discussing such complex end-of-life issues with patients is not easy. However, health care professionals should be supported and encouraged, as they build up close relationships with patients over time, to be more proactive in addressing the possibility of sudden deterioration, and ensuring that patients are fully informed of the possible consequences of potentially life-prolonging interventions. This should be reviewed on a regular basis during the illness trajectory, facilitated by the specialist palliative care team. By so doing, we will be in a better position to avoid stressful, unwarranted and inappropriate resuscitation attempts and complicated bereavement issues. Miss S Patricia D Enes Research Nurse, Princess Alice Hospice