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PubMed1997

Improving palliative care.

Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients. In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between foregoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.

Attitude of Health Personnel↗
PubMed2000

Beyond Bland: a critique of the BMA guidance on withholding and withdrawing medical treatment.

In Bland the House of Lords held it lawful to withdraw tube-feeding from a patient in a 'persistent vegetative state' (pvs), even with intent to kill him. The British Medical Association (BMA) recently published guidance on the withholding and withdrawal of 'medical treatment', so defined as to include food and water delivered by tube. The guidance endorses the withholding/withdrawal of tube-delivered food and water not only from patients in pvs but also from other non-terminally ill patients, such as those with severe dementia or serious stroke. The underlying justification appears (as in Bland) to be that such lives lack worth. This article offers three major criticisms of the guidance. First, its argument that tube-feeding is medical treatment rather than basic care is weak. Secondly, its reasons for not treating or tube-feeding undermine the BMA's long-standing opposition to active euthanasia and active assisted suicide. Thirdly, it relies heavily on legal precedent at the expense of ethical reasoning.

Dementia↗
PubMed1990

Letting and making death happen, withholding and withdrawing life-support: morally irrelevant distinctions.

The author argues that there is no morally relevant distinction between letting and making death happen, and between withholding and withdrawing life-support. There is a discussion of possible adverse consequences in believing that there are moral distinctions. And then he shows that acknowledging the absence of such a distinction does not necessarily imply any endorsement of active euthanasia.

Ethical Analysis↗
PubMed1996

Physicians' attitudes regarding Down syndrome.

We conducted a representative survey to obtain current information about attitudes of pediatricians, child neurologists, and pediatric surgeons in Hungary regarding Down syndrome. The findings are compared to those of a similar study from Canada. In the treatment of mentally handicapped newborns, none of the Hungarian doctors would choose active euthanasia; only a few percent would perform passive euthanasia. Hungarian doctors give priority to the hospital-based ethical committee in the decision-making process regarding the treatment versus nontreatment of a newborn with major congenital anomalies. In contrast to the Canadians, only a few doctors would discuss this question with parents and nurses. Most Hungarian physicians are not aware of legal regulations in this field. These attitudes can be explained by religious and cultural traditions different from the Canadian and Western European standards. The Hungarian medical community, like other Eastern European countries, is much more authoritative than the Canadian system. Furthermore, the appropriate legal regulations are not yet properly codified.

Adult↗
PubMed2003

"Death was a blessing"--should it ever be pharmaceutically hastened? British pharmacists' views.

OBJECTIVES: To investigate the views and experiences of British pharmacists in physician-assisted suicide (PAS) and voluntary active euthanasia (VAE) and to examine whether differences in views were associated with personal characteristics. METHOD: A postal questionnaire was mailed to a random sample of 500 registered pharmacists, with addresses in England or Wales, stratified according to sex and community/hospital working environments. MAIN OUTCOME MEASURE: Pharmacists' reports of their views and experiences of PAS and VAE. RESULTS: Completed questionnaires were received from 295 respondents (response rate: 59%). The majority of respondents (83%) reported that at times, a person had the right to choose their own manner of death; 61% and 53% thought that there should be changes in the Law to legalise VAE and PAS, respectively. If it were legal to do so, 63% stated that they would be willing to dispense medication for VAE and 64% for PAS. However, only 45% agreed that the pharmacist should have a role in advising the prescriber on the choice and dose of drugs used. Sex, age, and years registered as a pharmacist were not found to be significantly associated with views on the practices of PAS and VAE. However, pharmacists who reported having a religion were significantly less likely to favour such practices. On comparing the views of community and hospital pharmacists, community pharmacists were significantly less likely than expected to want to be informed about the intended purpose of lethal drugs. CONCLUSION: In this survey, while over half of British pharmacists did not disagree in principle to the legalisation of VAE and/or PAS, they were less supportive of direct involvement in such procedures. Religion was a discriminatory factor associated with negative views of VAE and PAS. The significant minority of pharmacists not wanting to know the purpose of drugs they suspected might be for PAS or VAE is not in accordance with professional accountability, reflecting the complex and sometimes conflicting legal and moral aspects of such practices when deciding upon a course of action.

Adult↗
PubMedDate not supplied

The Nazi! accusation and current US proposals.

In contemporary ethical discourse generally, and in discussions concerning the legalization of physician-assisted suicide (PAS) and voluntary active euthanasia (VAE) specifically, recourse is sometimes had to the Nazi! accusation. Some disputants charge that such practices are or will become equivalent to the Nazi 'euthanasia' program in which over 73,000 handicapped children and adults were killed without consent. This paper reflects on the circumstances that lead to the use of this charge and offers reasons for putting the Nazi! charge aside in contemporary discussions of PAS and VAE. A number of the philosophical presuppositions common to both the Nazi 'euthanasia' program and the currently proposed practices of PAS and VAE are examined. Noting that racist ideology and violent coercion characterized the Nazi program, the paper concludes with a cautionary consideration of the current circumstances that would specify PAS and VAE in the US.

Attitude↗
PubMed1990

Changing attitudes and practices in foregoing life-sustaining treatments.

Advances in medical technology and practices have been associated with improved patient outcomes. At times, the price of this progress has included great financial costs and human suffering. During the last two decades, there have been significant changes in medical practices in America. In the late 1960s and early 1970s, the removal of a respirator or hydration or nutrition from a patient who was not brain dead was considered a deviation from accepted medical practices. In 1976, the Quinlan case allowed the removal of a ventilator from a patient in a persistent vegetative state. Subsequent court decisions in the 1980s have equated hydration and artificial feeding with other forms of life-sustaining treatments and have allowed their withdrawal in patients who were not terminally ill. Prominent physicians have recently stated that it is not immoral for a physician to assist in the rational suicide of a terminally ill patient. Active euthanasia programs in the United States are likely in the near future.

Attitude to Death↗
PubMed1993

Dissociation between the wishes of terminally ill parents and decisions by their offspring.

OBJECTIVE: To assess the attitude and factors affecting decision-making by offspring for life-sustaining measures toward their elderly terminally ill parents. DESIGN: Survey SETTING: Acute geriatric department of a university-affiliated teaching hospital. PATIENTS AND PARTICIPANTS: 108 offspring of 48 terminally ill elderly patients were interviewed. MEASUREMENTS: The attitude of offspring regarding life-sustaining measures based on a comprehensive questionnaire, administered by face-to-face interview, that included clinical, social, and religious information for each patient and social, religious, demographic, and educational information for each family member. RESULTS: A significant majority requested the continuation of fluid, nutrition, and medication (78%, 66%, 73%, respectively). A minority of 25%-29% requested the initiation of resuscitation, mechanical ventilation, and dialysis. Active euthanasia was requested by seven offspring. Factors that significantly affected offspring's decisions were the degree of religious observance and close relationship. Approximately 50% of offspring believed they knew their parents' wishes, but most of them did not comply with the parents' wishes. The offspring's preferences for themselves differed in important aspects from the requests for their parents. The great majority stated that a family member and/or the responsible physician should be involved in the decision-making process (76% and 79%, respectively). Only 2.0% suggested the participation of an ethics committee, and the court was rejected by all. CONCLUSIONS: Basic life-sustaining measures are requested for the terminally ill parents by most of the offspring. A significant minority even requested aggressive life-sustaining measures. The degree of religiosity and closeness of relationship influenced offspring's request most strongly.

Adult Children↗
PubMedDate not supplied

Bioethics and political ideology: the case of active voluntary euthanasia.

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

Attitude↗
PubMed1992

The method of 'principlism': a critique of the critique.

Several scholars have recently criticized the dominant emphasis upon mid-level principles in bioethics best exemplified by Beauchamp and Childress's Principles of Biomedical Ethics. In Part I of this essay, I assess the fairness and cogency of three broad criticisms raised against 'principlism' as an approach: (1) that principlism, as an exercise in applied ethics, is insufficiently attentive to the dialectical relations between ethical theory and mortal practice; (2) that principlism fails to offer a systematic account of the principles of non-maleficence, beneficence, respect for autonomy, and justice; and (3) that principlism, as a version of moral pluralism, is fatally flawed by its theoretical agnosticism. While acknowledging that Beauchamp and Childress's reliance upon Ross's version of intuitionism is problematic, I conclude that the critics of principlism have failed to make a compelling case against its theoretical or practical adequacy as an ethical approach. In Part II, I assess the moral theory developed by Bernard Gert in Mortality: A New Justification of the Moral Rules, because Gert has recommended his approach as a systematic alternative to principlism. I judge Gert's theory to be seriously incomplete and, in contrast to principlism, unable to generate coherent conclusions about cases of active euthanasia and paternalism.

Beneficence↗
PubMed2000

Applied ethics: what kind of ethics and what kind of ethicist?

Types of ethics are classified as more or less holistic in three respects. Current forms of applied ethics (among them reflective equilibrium) are criticized for being reductionist rather than holistic. It is claimed that applied ethics ought to be of a holistic kind. Two examples (tracing of hereditary cancer and active euthanasia) are used for maintaining that a reductionist ethic is of limited use for solving practical moral problems. Some possible roles of the ethicist are discussed. It is maintained that the ethicist ought to be a life philosopher mapping the moral landscape or a personal mentor rather than being a policeman or an ethics engineer.

Ethical Theory↗
PubMedDate not supplied

U.K. physicians' attitudes toward active voluntary euthanasia and physician-assisted suicide.

A comparison of the views of geriatric medicine physicians and intensive care physicians in the United Kingdom on the topics of active voluntary euthanasia and physician-assisted suicide revealed rather different attitudes. Eighty percent of geriatricians, but only 52% of intensive care physicians, considered active voluntary euthanasia as never justified ethically. Gender and age did not play a major part in attitudinal differences of the respondents. If the variability of attitudes of these two medical specialties are anywhere near illustrative of other physicians in the United Kingdom, it would be difficult to formulate and implement laws and policies concerning euthanasia and assisted suicide. In addition, ample safeguards would be required to receive support from physicians regarding legalization.

Attitude↗
PubMedDate not supplied

A good death: is euthanasia the answer?

Euthanasia--particularly active voluntary euthanasia--and assisted suicide are subjects of continuing controversy. Historical attitudes, current concerns, the situation in the Netherlands, and the positions of various medical associations are reviewed. Major arguments for and against active euthanasia are presented, with special consideration to the role that health care providers might be asked to perform should active euthanasia and assisted suicide be given societal sanction. The authors conclude that better pain management and A willingness to provide care within already established ethical and legal guidelines, not the legalization of active euthanasia and assisted suicide, are the appropriate responses to current proposals for assistance in dying.

Attitude↗
PubMedDate not supplied

Why does removing machines count as "passive" euthanasia?

The distinction between "passive" and "active" euthanasia, though problematic and highly criticized, retains a certain intuitive appeal. When a patient is allowed to die, nature appears simply to be taking its course. Yet when a patient is killed by, say, a lethal injection, humans appear to be causing his or her death. Guilt seems to follow naturally from the latter act while not from the former. Yet this view only holds up if age-old and vague ideas about "nature" and "artifice" go unscrutinized. Once examined more closely the functional relevance of particular machines to particular bodies becomes evident. And the innocence and guilt less clear.

Adult↗
PubMed2000

A comparison of resident and faculty attitudes toward physician-assisted suicide and active voluntary euthanasia.

PURPOSE: Assisted death practices such as physician-assisted suicide (PAS) and active voluntary euthanasia (AVE) are becoming more acceptable to the public and the medical profession. This study compared the attitudes and practices of resident house staff physicians with the medical staff physicians responsible for teaching them regarding PAS and AVE. METHODS: A convenience sample of 372 medical staff and 105 resident house staff from a multi-residency community teaching hospital were anonymously surveyed. The overall response rate was 47%. The questionnaire consisted of 10 questions that examined the subjects' professional and legal values, willingness to participate in assisted death practices, and personal preferences for assisted death practices. RESULTS: The resident house staff differed significantly from the medical staff in attitudes toward assisted death practices. The resident house staff was less likely to support the traditional prohibitions against PAS and AVE. The resident house staff was also more likely to offer assisted death practices if they were legal. There was no significant difference, however, in the participation of assisted death practices between the groups respectively for PAS and AVE. The residents were more likely to request PAS or AVE for themselves or family members. CONCLUSIONS: There are significant differences in attitudes and practices between resident physicians and medical staff physicians concerning PAS and AVE. These differences could lead to professional conflicts when setting clinical goals for end-of-life care and could compromise patient care.

Attitude of Health Personnel↗
PubMed1998

Nurse characteristics and attitudes to active voluntary euthanasia: a survey in the Australian Capital Territory.

While surveys of Australian nurses' attitudes to active voluntary euthanasia (AVE) have found that the majority are in favour, there may be important differences between subgroups of nurses. This paper investigates the role of the following nurse characteristics on nurses' attitudes to AVE: age, gender, religion, amount of contact with terminally ill patients, area of specialty, and degree of interest taken in the issue of AVE. A postal survey on AVE was carried out in late 1996 of 2000 randomly selected registered nurses from the Australian Capital Territory. Responses were received from 1218 nurses (61%). The survey included a question asking whether the law should be changed to allow doctors to take active steps to bring about a patient's death under some circumstances. Overall, 69% of respondents agreed that the law should be changed. Those nurses who were more likely to agree were under the age of 40 years, agnostic, atheist or of the Anglican religion, to have less contact with terminally ill patients, to work in the area of critical care or mental health, and to take less interest in the issue of AVE. Palliative care nurses were the only subgroup without a majority in favour (33%). There is other evidence in the euthanasia literature, that nurses and doctors are less in favour of AVE than the general public. Taken together with the present findings, it can be concluded that attitudes towards AVE are more favourable in people who have less contact with the terminally ill.

Adult↗