Factors that Influence End-Of-Life Decision Making Amongst Attending Physicians

Background: Medical advances prolong life and treat illness but many patients have chronically debilitating conditions that prevent them from making end-of-life (EOL) decisions for themselves. These situations are difficult to navigate for both patient and physician. This study investigates physicians’ feelings and approach toward EOL care, physician-assisted suicide (PAS), and euthanasia. Methods: An anonymous, self-administered online survey was distributed through the New Jersey Medical School servers and American College of Surgeons forums. The survey presented clinical EOL vignettes and subjective questions regarding PAS and euthanasia. Results: We obtained 142 responses from attending physicians. Respondents were typically male (61%), married (85%), identified as Christian (54%), had more than 20 years of experience (55%), and worked at a university hospital (57%). Religious beliefs and years of work experience seemed to be significant contributors in EOL decision making, whereas gender and medical specialty were not significantly influential. Conclusion: Factors such as years of work experience and religious belief may influence medical professionals’ opinions about PAS and euthanasia and their subsequent actions regarding EOL care. In many cases, the boundaries are blurred and require further study before concrete conclusions can be made.

The Slippery Slope Argument in the Context of Euthanasia and Assisted Suicide

This article analyzes the slippery slope argument and its application to the problem of legalizing euthanasia and physician-assisted suicide. The argument is often referred to in discussions of abortion, in vitro fertilization, etc., but it has been little developed in the Russian-language literature. This explains the relevance and novelty of this article. The focus is on the ways of representation of the argument in research. It distinguishes its main types: logical (disintegrating into no-principle distinction argument and the soritical argument), empirical (or psychological argument), and non-logical (metaphorical). Each of these types of argument is constructed according to a certain principle and has a number of features and critiques. A common place for criticism of an argument is its focus on the future so that it makes reasoning probabilistic. The logical type of argument is centered around denoting the transition between the original event and its adverse consequences and denotes the action of social factors to accelerate the transition. The no-principal distinction argument implies that there is no moral distinction between the events at the beginning and the end of the slope. The soritical argument involves intermediate steps between questionable and unacceptable practices. The conceptual slope is another variant of the logical kind of argument. The empirical argument illustrates a situation of changing societal values which results in an easier acceptance of morally disapproved practices. The metaphorical argument is used to illustrate the metaphor of slope and the situation of the accumulation of small problems that lead to serious undesirable results. The non-logical kind of argument centers around the routinization of practice, desensitization, and exploitation of unprotected groups in society. Exploitation can be called the victims' slope. It grounds its consideration on the abuse of the practice being administered. Application of the ethical methodology (theoretical-logical and empirical-historical) to the types of arguments and ways of their application allows us to highlight the value component of the argument, to determine its dilemma nature and to correlate it with bioethical principles. The application of bioethical principles to suppress the transition to undesirable consequences is critiqued on the basis of particularly difficult cases in which one is unable to articulate one's decision. The criticism of the argument is built on the probabilistic nature of the reasoning, the lack of reflection on the underlying premise and the lack of empirical evidence. It concludes that the slippery slope argument is incapable of being the only valid justification for rejecting the practices of physician-assisted suicide and euthanasia.

Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence

There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.

Consumer Medicine’s Origins and Harms

Consumer medicine consists of medical interventions pursued for non–health-related goals with the locus of the goals residing solely with the patient. Currently, contraceptives, abortion, cosmetic procedures, and physician-assisted suicide (PAS)/euthanasia fall in this category. Consumer medicine originates from the fusion of expressive individualism with its sole focus on the subjective psychological well-being intersecting with an expansion of health now including well-being combined with an exaltation of autonomy. Expressive individualism is inward-focused and entirely subjective reducing the human to a psychologic self while instrumentalizing the biological and social dimensions and neglecting the spiritual dimension. Expressive individualism is currently manifested through economic activity (career and consumption) and particularly sexual expression. This contrasts with the holistic biopsychosocial-spiritual model of health with its deep inter-relationships and prioritization of the spiritual. Consumer medicine has damaged the profession of medicine. Physicians now have conflicting roles of healer versus body engineer, and conflicting obligations to do no harm while performing medical harms unrelated to objective health. There is now division within medicine and increasing external state regulations both seriously harming its professional status. The traditional teleologically driven ethical framework that is objectively disease-focused is now confused with a subjective list of non–health-related values as goals for medical interventions leading to an incoherent ethical framework. Biologic solutions best address biological problems and do not effectively address psychological, social, or even spiritual problems but rather make them worse. Medicine now reinforces and is complicit with expressive individualism and its attendant shallow and narrow understanding of what it means to be human with the current valuation of sexual expression and economic activity. Medical harms and social costs have resulted while challenging the value of those who are disabled, elderly, or marginalized. This shallow view has likely fueled the current existential crisis contributing to the marked increase in PAS/euthanasia in the West. Summary: Consumer medicine currently includes contraceptives, abortion, cosmetic procedures, and physician-assisted suicide (PAS)/euthanasia. These medical interventions are pursued for subjective non–health-related goals as opposed to the traditional goal of treating sick patients for their objective health. Consumer medicine’s origins lie in the intersection of expressive individualism, the exaltation of patient autonomy combined with health’s redefinition as subjective well-being. This has resulted in harms to the profession of medicine, ethical incoherence, and medical injury. Consumer medicine promotes a truncated understanding of the human at odds with the biopsychosocial-spiritual model and human flourishing. This has likely contributed to the rise of PAS/euthanasia.

Referral vs Transfer of Care: Ethical Options When Values Differ

Conscientious objection (CO) in medicine is where a healthcare professional (HCP) firmly opposes, with an expression of reasoned disapproval, a legally available procedure or treatment that is proscribed by one’s conscience. While there remains controversy regarding whether conscientious objection should be a part of medicine, even among those who support CO state that if the HCP does not provide the requested service such as abortion, physician assisted suicide, etc., there is an obligation on the part of the objecting HCP to refer to someone who will provide it. However, referral makes the referring HCP complicit in the act the referrer believes to be immoral since the referrer has a duty to know that the HCP who will accept the patient is not only able to do the procedure but is competent in its performance as well. The referrer thus facilitates the process. Since one has a moral obligation to limit complicity with immoral actions when it cannot be avoided, the alternative is to allow the patient to transfer care to another when the patient has made the autonomous decision to reject the advice of the HCP.

Understanding the Voices of Disability Advocates in Physician-Assisted Suicide Debates

Christians have an obligation to attend to the voices of persons who are crying out that their dignity and very lives are in jeopardy when physician-assisted suicide (PAS) becomes legalized. The following essay begins with an account of the concept of “disability moral psychology,” which elucidates the unique ways persons with disabilities perceive the world, based on their phenomenological experience. The author then explores the disability critique of PAS and the shared social conditions of persons who are chronically disabled and terminally ill. Finally, the author positions the disability critique within Christian moral deliberations on PAS to unearth its significance for Christian ethics. To bear witness to a compassionate God, theological and ethical judgments concerning PAS must seek perspectives from persons who claim that their dignity and even their lives are in jeopardy by the practice.

Physician-Assisted Suicide and Euthanasia: Theological and Ethical Responses

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to “die well?” Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justified practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies are addressed as the practice of PAS is popularized.

Physician Assistance in Dying: An Option for Christians?

Opposition to physician-assisted suicide is widespread in Christian ethics. However, on a topic as controversial as physician-assisted suicide, no one can reasonably speak for “the Christian” perspective. Natural-law and, specifically, just-war thinking are claimed in the Christian tradition, yet the natural-law contribution to a Christian ethical analysis of physician-assisted suicide requires explanation and defense. Natural-law ethical theory affirms the central role of reason in moral thinking and provides a theoretical resource in contemporary ethics to assist in analyzing specific moral issues, problems, and conflicts. This essay seeks to demonstrate how just-war thinking, derived from natural-law tradition, allows movement from the theoretical world of natural-law theory to the practical world of normative ethics. Here the case is made that the just-war model of ethics helps elucidate the moral problematic involved in physician-assisted suicide while clarifying direction on this particularly thorny and controversial problem.

How to reveal disguised paternalism: version 2.0

Background We aim to further develop an index for detecting disguised paternalism, which might influence physicians’ evaluations of whether or not a patient is decision-competent at the end of life. Disguised paternalism can be actualized when physicians transform hard paternalism into soft paternalism by questioning the patient’s decision-making competence. Methods A previously presented index, based on a cross-sectional study, was further developed to make it possible to distinguish between high and low degrees of disguised paternalism using the average index of the whole sample. We recalculated the results from a 2007 study for comparison to a new study conducted in 2020. Both studies are about physicians’ attitudes towards, and arguments for or against, physician-assisted suicide. Results The 2020 study showed that geriatricians, palliativists, and middle-aged physicians (46–60 years old) had indices indicating disguised paternalism, in contrast with the results from the 2007 study, which showed that all specialties (apart from GPs and surgeons) had indices indicating high degrees of disguised paternalism. Conclusions The proposed index for identifying disguised paternalism reflects the attitude of a group towards physician assisted suicide. The indices make it possible to compare the various medical specialties and age groups from the 2007 study with the 2020 study. Because disguised paternalism might have clinical consequences for the rights of competent patients to participate in decision-making, it is important to reveal disguised hard paternalism, which could masquerade as soft paternalism and thereby manifest in practice. Methods for improving measures of disguised paternalism are worthy of further development.

Dying under a Description? Physician-Assisted Suicide, Persons, and Solidarity

Debates over physician-assisted suicide (PAS) comprise a small portion of broader culture wars. Their role in the culture wars obscures an under-acknowledged consensus between those who support PAS and those who oppose it. Drawing insights from personalism, this essay situates PAS within larger moral obligations of solidarity with the dying and their caregivers. The contributions of Roman Catholic personalism relocate debates over PAS and allow us to harness shared moral impulses.