Udo Schuklenk

End‐Of‐Life Decision‐Making in Canada: The Report by the Royal Society of Canada Expert Panel on End‐Of‐Life Decision‐Making

This report on end-of-life decision-making in Canada was produced by an international expert panel and commissioned by the Royal Society of Canada. It consists of five chapters. Chapter 1 reviews what is known about end-of-life care and opinions about assisted dying in Canada. Chapter 2 reviews the legal status quo in Canada with regard to various forms of assisted death. Chapter 3 reviews ethical issues pertaining to assisted death. The analysis is grounded in core values central to Canadas constitutional order. Chapter 4 reviews the experiences had in a number of jurisdictions that have decriminalized or recently reviewed assisted dying in some shape or form. Chapter 5 provides recommendations with regard to the provision of palliative care in Canada, as well as recommendations for reform with respect to the various forms of assisted death covered in this document.

The standard of care debate: against the myth of an “international consensus opinion”

It is argued by Lie et al in the current issue of the Journal of Medical Ethics that an international consensus opinion has formed on the issue of standards of care in clinical trials undertaken in developing countries. This opinion, so they argue, rejects the Declaration of Helsinki’s traditional view on this matter. They propose furthermore that the Declaration of Helsinki has lost its moral authority in the controversy in research ethics. Although the latter conclusion is supported by this author, it will be demonstrated in this paper that there is not such a thing as an international consensus opinion, and that the authorities used by Lie et al as evidence in support of their claim should not be relied upon as authorities or final arbiters in this debate. Furthermore, it will be shown that arguments advanced substantively to show that lower standards of care are ethically acceptable in the developing world, conflate scientific with economic reasons, and ultimately fail to bolster the case they are designed to support.

Treatment-resistant major depressive disorder and assisted dying

Competent patients suffering from treatment-resistant depressive disorder should be treated no different in the context of assisted dying to other patients suffering from chronic conditions that render their lives permanently not worth living to them. Jurisdictions that are considering, or that have, decriminalised assisted dying are discriminating unfairly against patients suffering from treatment-resistant depression if they exclude such patients from the class of citizens entitled to receive assistance in dying.

Professional responsibilities of biomedical scientists in public discourse

This article describes how a small but vocal group of biomedical scientists propagates the views that either HIV is not the cause of AIDS, or that it does not exist at all. When these views were rejected by mainstream science, this group took its views and arguments into the public domain, actively campaigning via newspapers, radio, and television to make its views known to the lay public. I describe some of the harmful consequences of the group’s activities, and ask two distinct ethical questions: what moral obligations do scientists who hold such minority views have with regard to a scientifically untrained lay audience, and what moral obligations do mainstream newspapers and government politicians have when it comes to such views. The latter question will be asked because the “dissidents” succeeded for a number of years in convincing the South African government of the soundness of their views. The consequences of their stance affected millions of HIV infected South Africans severely.

Treatment-resistant major depressive disorder and assisted dying: response to comments

The commentaries responding to our article on treatment-resistant depression and assisted dying focus on the following issues: epistemological questions about death, patient competence, the role of doctors, the moral basis of the right to an assisted death, safety and security of patients, and questions about various cases that occurred in the Netherlands. We will address in our response each of these concerns, beginning with the last issue first. Dr den Hartogh mentions a case in the Netherlands where the Dutch review committee deemed ‘the doctor … not careful’.1 This case was published after we submitted our paper. The case was judged ‘not careful’ because no psychiatrist had been consulted to consider the competence of the patient, and to review whether the patients situation was truly of a hopelessness nature. In this case, the doctor who performed the euthanasia and the consultant were general practitioners. This case does not undermine our argument. The review committee did not suggest that the patient was incompetent. In our paper, we are careful to consider only treatment-resistant competent patients. Dr Cowley mentions the so-called Chabot case and the Brongersma case.2 In the Netherlands, the Brongersma case is not discussed under the label ‘depression’, but as a case of a patient who was ‘tired of life’.3 Eighty-six-year-old former politician Edward Brongersma did not suffer from a mental or other illness. It deserves a separate discussion and is outside the scope of our paper. The Chabot case was extraordinary because the patient had no wish to be cured from her depression because she felt depression to be an appropriate state to be in after the premature deaths of her two sons.4 This case also falls outside the scope of our paper. Drs Broome and de Cates begin their discussion with an epistemological argument …

Should We Use the Criminal Law to Punish HIV Transmission

Legislators around the world are grappling with the question of whether or not the criminal law should be deployed in order to punish HIV transmission that is the result of voluntary sexual encounters between competent, consenting adults. A few years ago, when I was working in South Africa, that country’s Law Reform Commission proposed to declare HIV transmissions that are the result of voluntary sexual encounters among competent consenting adults a criminal offence that ought to fall under the category of rape (Schuklenk, 2003). Rape and voluntariness do not go too well together, so – not being a lawyer – I was surprised about the seemingly otherworldly machinations of legal minds in the context of HIV/AIDS. Matthew Weait points out in his book Intimacy and Responsibility: The Criminalisation of HIV Transmission that many liberal democracies have made HIV transmission a criminal offence, among these Canada, Sweden, Germany, Norway, Denmark, the Netherlands, the UK and many others. In most countries, HIV infected people who demonstrably knew about their infection have been successfully prosecuted for transmitting HIV to their sexual partners.

Canada on course to introduce permissive assisted dying regime

Canadas Supreme Court decided in February 2015 that the criminalisation of assisted dying in the country violates the countrys citizens and residents constitutional rights. This paper reviews policy recommendations produced by a special expert advisory panel appointed by Canadas provinces and territories, where the responsibility for the provision of health care lies. It also reviews a similar document produced by a special federal parliamentary committee. Based on the review of these two milestone documents it is argued that a Canadian consensus seems to emerge that foreshadows a permissive regulatory regime in that country.

Are Concerns About Irremediableness, Vulnerability, or Competence Sufficient to Justify Excluding All Psychiatric Patients from Medical Aid in Dying?

Some jurisdictions that have decriminalized assisted dying (like Canada) exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to this service amount to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system.

Conscientious objection in medicine: accommodation versus professionalism and the public good

Introduction In recent years questions have arisen about the moral justification for the accommodation of health care professionals who refuse, on conscience grounds as opposed to professional grounds, to provide particular professional services to eligible patients who request that kind of service. Source of data Literature review. Areas of disagreement Central to concerns about the accommodation claims of conscientious objectors is that health care professionals volunteer to join their professions that typically they are the monopoly providers of such services and that a health care professionals refusal to provide professional services on grounds that are not professional judgements amounts to unprofessional conduct. Defenders of conscientious objection maintain that in a liberal society respect for a professionals conscience is of sufficient importance that conscientious objectors ought to be accommodated. To deny conscientious objectors accommodation would reduce diversity in the health care professions, it would deny objectors unfairly equality of opportunity, and it would constitute a serious threat to the moral integrity of conscientious objectors. Growing points The legal literature on the subject is growing due to the impossibility of satisfactory compromises.

The ethical case against assisted euthanasia has not been made

utility. Today, these patients enjoy a surgical survival that is higher than that for patients unaffected by Down syndrome. This result, unimaginable 4 decades ago, came about only through the efforts of those who refused to identify these patients as ‘‘inoperable.’’ Had we embraced euthanasia at that time, this would have been nearly impossible. Consider further the progress in single-ventricle repairs, arrhythmia treatments, and transplants, treatments unthinkable a few decades ago that have happened only by first rejecting euthanasia as an option for what was once thought ‘‘hopeless.’’ Intentional euthanasia of infants is morally unacceptable: it advocates selective termination of life on the basis of dangerously subjective definitions, which history has shown impossible to contain. Furthermore, it abandons the hope of medical progress. Both are directly contrary to Hippocratic principles.