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Objectives: This study revisited the complexities faced by physicians in meeting due care criteria for euthanasia in patients with advanced dementia in The Netherlands. Despite increasing cases and legal provisions for advance euthanasia directives (AEDs), physicians encounter challenges with ethical issues, including patient communication and assessing unbearable suffering in patients who lack decisional capacity. This study examines the perspectives of elderly care physicians (ECPs), support and consultation on euthanasia in The Netherlands (SCEN) physicians, and euthanasia expertise center (EEC) physicians., Design: A multimethod descriptive study using a questionnaire with both closed and open-ended questions., Setting and Participants: This study explores the complexities faced by physicians in handling AED-based euthanasia requests of patients with advanced dementia., Methods: Baseline characteristics of physician subgroups were analyzed descriptively, and subgroup variations were assessed using univariate regression. Qualitative data underwent thematic content analysis., Results: With a 13.8% response rate, the study included 290 participants: 108 ECPs, 188 SCEN physicians, and 53 EEC physicians. Some had combined roles: ECP and SCEN physicians (n = 29), ECP and EEC physician (n = 1), SCEN physicians and EEC physicians (n = 17), and ECP, SCEN physicians, and EEC physicians (n = 6). ECPs received most AED-based euthanasia requests but only 7 EEC physicians and 1 SCEN physician performed euthanasia. All subgroups stressed the importance of patient communication. ECPs found euthanasia ethically justifiable only when communication was possible, highlighting the need to understand current euthanasia wishes and verify unbearable suffering. Effective communication was deemed crucial for confirming request relevance, identifying obstacles, involving patients, fostering trust, and alleviating fears. Physicians generally agreed that unbearable suffering could be assessed through patient expressions, observations, and family input., Conclusions and Implications: Despite receiving AED-based euthanasia requests, few physicians proceeded. Subgroup analysis showed varying views, with ECPs emphasizing communication and EEC physicians focusing on determining unbearable suffering. All subgroups highlighted the importance of current patient expressions and involvement in the decision-making process., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The Dutch Euthanasia law permits euthanasia in patients with advanced dementia lacking decisional capacity based on advance euthanasia directives. Nevertheless, physicians encounter difficulties assessing the criteria for due care in such cases. This study explores the perspectives of legal experts on the fulfillment of these criteria and the potential for additional legal guidance to support physicians' decision-making processes., Methods: A qualitative study was conducted with legal experts. Two focus group sessions were conducted. The data analysis was conducted iteratively, with the data being interpreted using thematic content analysis and the framework method., Results: Participants emphasize the importance of considering the patient's current wishes and informing them about the limitations of advance euthanasia directives. While representatives and healthcare professionals can assist in interpreting wishes, the final decision regarding euthanasia rests with the physician. The participants also discuss the challenges posed by pre-recorded wishes due to changing preferences. Furthermore, they present different views on the value of life wishes of patients with advanced dementia. While some participants prioritize life wishes over advance euthanasia directives, others question whether such expressions still reflect their will. Participants find it essential to assess unbearable suffering in the context of the current situation. Participants acknowledge the necessity to interpret advance euthanasia directives but also current expressions and they entrust this interpretation to physicians, viewing them as the primary authority, despite consulting multiple sources., Conclusions: The Dutch Euthanasia law's due care criteria are open norms -which are open in substance and require further elaboration, mostly determined on a case-by-case basis to the field standards of the profession-, placing the responsibility on physicians to interpret advance euthanasia directives and patient expressions. Despite potential support from various sources of information, there is limited additional legal guidance available to assist physicians in making decisions., (© 2024. The Author(s).)

In recent decades, many jurisdictions have moved toward legalizing euthanasia and assisted suicide, alongside a near-universal increase in public acceptance of medical aid in dying. Here, we draw on a comprehensive quantitative review of current laws on assisted dying, experimental survey evidence, and four decades of time-series data to explore the relationship between these legislative transitions and change in moral attitudes. Our analyses reveal 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. Fulfillment of these eligibility criteria elevates public moral approval of physician-assisted death, equally in countries with (i.e., Spain) and without (i.e., the United Kingdom) assisted dying laws. Finally, historical records of public attitudes toward euthanasia across numerous countries uncovered anticipatory growth in moral approval leading up to legalization, but no accelerated growth thereafter. Taken together, our findings suggest that the enactment of medical aid in dying laws, and their specific provisions, crystallize patterns in moral intuition., Competing Interests: Competing interests statement:The authors declare no competing interest.

Almost a year after the enactment of the law regulating euthanasia in Spain, public opinion was shocked to learn that a defendant in criminal proceedings obtained medical assistance in dying following injuries sustained in an exchange of gunfire with the police after having committed a series of severe crimes. Although there are very few cases in the world where prisoners have received euthanasia, the one we will discuss in this article is the only known case where both the public prosecutor's office and the private prosecutors judicially opposed the defendant's euthanasia. This article aims to offer a new perspective on the ethical legitimacy of detainees' access to euthanasia: the ethics of caring solidarity. To do this, we will first place the case in its legal context. Subsequently, we will address the two main arguments proposed in the literature to justify euthanasia in detention: respect for the autonomy of the detainee and the principle of equivalence of care. Finally, after having identified serious shortcomings in both arguments, we will argue that the perspective of caring solidarity offers a better ethical basis for people in detention's access to euthanasia., (© 2024 The Author(s). Bioethics published by John Wiley & Sons Ltd.)

The most controversial issue in the Dutch euthanasia practice concerns the performance of euthanasia in a case of a patient in an advanced state of dementia on the basis of a request that is laid down in an advance directive. This is particularly controversial when such a patient, although lacking decisional capacity on the matter, shows signs of a wish to live. In two important verdicts of April 21 2020 the Dutch Supreme Court has ruled that a request that has been made competently cannot be revoked incompetently. In this comment I consider two recent documents from Dutch professional organisations that are contrary to these decisions, in particular a guideline stating that on a proper understanding of decisional capacity the expression of a wish to live of a demented person, however inarticulate, should always be considered to be made competently.

This article explores nursing, patient records, and ideology within the context of the National Socialist "euthanasia" program ( Aktion T4) in Germany and Austria from 1939 to 1941, which targeted individuals with mental and physical disabilities for systematic killing. Using Hannah Arendt's concept of the "banality of evil," it examines how ordinary individuals, including nurses, became agents of atrocity by adhering to bureaucratic orders. Jacques Ellul's Ethics of Technology framework is employed to analyze how National Socialist ideology manipulated technological processes to enhance efficiency in genocidal goals. Propaganda was crucial in garnering public support, blurring the lines between technology, ethics, and ideology. Archival research at documentation centers and national archives reveals methods for deciding who was killed, the role of family in medical records, and nurses' involvement in the T4 operation. Three narratives of T4 victims illustrate the personal impacts of these bureaucratic and ideological practices. The article reflects on contemporary nursing, emphasizing the importance of ethical standards and vigilance against data and misuse of technology in health care. This historical examination serves as a reminder of the potential consequences of depersonalization and blind adherence to institutional priorities, underscoring the need for critical engagement with the ethical dimensions of nursing practice., Competing Interests: DisclosureThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background & objectives: Identifying the impacts of COVID-19 on patients' and practitioners' access to legal assisted dying and euthanasia (AD&E) services is vital to informing service continuity in an ongoing pandemic. Methods: An anonymous online survey collected qualitative and quantitative data from health practitioners and agencies providing legal AD&E services ( n = 89), complemented by semi-structured interviews with 18 survey respondents who volunteered. Results: Following governments' responses to the dynamic pandemic context, rates of AD&E inquiries and requests fluctuated across and within jurisdictions, based on a complex interaction of factors affecting patient access to AD&E agencies and assessors as services were disrupted. Service flexibility and nimbleness became key elements in continuing service availability and included calculated 'rule-breaking' considered justifiable to adhere to established bioethics. Making innovative adjustments to usual practice led to reviewing the effectiveness of AD&E services and laws, resulting in providers now improving services and lobbying for legislative change., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Context: Palliative Care (PC) and Medically Assisted Death (MAD), specifically assisted suicide and euthanasia, are distinct practices characterized by differing objectives, methods, implementation and outcomes. Representatives of PC, including scientific societies or physicians, may, in certain cases, adopt a critical stance towards MAD., Objectives: The study aims to explore the underlying reasons for such opposition., Methods: To this end, the philosophical underpinnings and legal conditions of PC and MAD will be analyzed., Results: The ethical and philosophical landscape of PC and MAD leads us to identify, on one hand, the Hippocratic paradigm and, on the other hand, what we call Socratic medicine. From a legal analysis perspective, the presence of intolerable suffering serves as a common ground between the two practices, albeit risking being the subject of misunderstandings and instrumental objections., Conclusion: Preventing an instrumental use of PC in relation to MAD is crucial to enable the respect and the coexistence of the two practices., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The issue of end-of-life care is the subject of a sensitive debate in French society, particularly regarding the possibility for certain patients to have access to medical assistance in dying. The aim of this study was to assess the knowledge and opinion of healthcare providers on the care practices for patients at the end of life, as well as to highlight any specificities in their discourse., Method: A survey of healthcare providers' opinions, composed of closed and open questions, that were analyzed using a lexicometric approach, was distributed in a cancer center., Results: The results of the study reveal a good knowledge of the different procedures. Professionals considered that advance directives should be systematically collected; a majority of them differentiated euthanasia from deep continuous sedation and perceived the latter as a means of relieving patients' suffering without inducing death. The different procedures related to the active assistance in dying were known by a majority of professionals and the survey did not identify a dominant trend concerning the will to practice euthanasia if the legal framework allowed it. Half of the participants considered their training insufficient, indicating the need to fill this gap., Discussion: This survey underlines the importance of training and support for the professionals caring for patients in palliative situation and their relatives in France., (Copyright © 2024 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

No abstract available.

Abstract: Recent events have brought the debate on end-of-life issues to the forefront, particularly regarding the principle of self-determination for depressed patients. Belgian legislation, in fact, allows for requesting euthanasia when patients, capable of expressing their own will consciously, suffer in an unbearable manner and find no meaning in continuing their existence, even in the absence of incurable and/or severely debilitating conditions. The state of the art is an increasing number of people who die from euthanasia. An open question is when a situation can be defined as unbearable. Moreover, does such an assessment necessarily lead to death, or are there other solutions? In our opinion, such a practice should be limited to prevent inappropriate applications that could lead to infringing depressed patients' rights.

Euthanasia is categorically prohibited in Pakistan by Islamic law, but a clash of opinions among doctors and human rights advocates still prevails. As a result, medical students are becoming concerned about its practice and this problem needs to be addressed. A cross-sectional study was conducted at Faisalabad Medical University (FMU), Pakistan, from April 2023 to May 2023, using random sampling and statistical programme SPSS version 25, to assess the attitudes of medical students regarding euthanasia and physician-assisted suicide (PAS). Despite the conditions and scenarios presented to the students, most of them expressed opposition to euthanasia and physician-assisted suicide because of their religious beliefs and optimistic approach to life. Most of them favoured palliative care and passive euthanasia. Some students showed compliance with euthanasia even though it is equivalent to murder in Islam. Such contrasting results can baffle a physician to make wise decisions. Hence, it must be covered in medical curriculum in depth in order to help the future physicians clearly understand its practice under all circumstances.

Through the late-twentieth century, physicians endorsed the denial of life-saving surgeries to infants because they had Down syndrome. Grim physician assessments of the inevitable burden of Down syndrome found ideological footing in the 1970s crusade to eradicate the condition, a public health goal made possible by new genetic diagnostics and a weakened abortion law. What is most striking about this physician-sanctioned passive euthanasia is that it persisted even in an era of unprecedented expansion of disability rights. Physician endorsement of the euthanasia of infants with Down syndrome offers a powerful corrective to the notion that post-war Canada was marked by waning support for eugenics. Medically sanctioned euthanasia of babies because of their Down syndrome, eugenics of the most extreme type, thrived in late-twentieth century Canada.

Although in Italy there is currently no effective law on physician-assisted suicide or euthanasia, Decision No. 242 issued by the Italian Constitutional Court on September 25, 2019 established that an individual who, under specific circumstances, has facilitated the implementation of an independent and freely-formed resolve to commit suicide by another individual is exempt from criminal liability. Following this ruling, some citizens have submitted requests for assisted suicide to the public health system, generating a situation of great uncertainty in the application processes. As a matter of fact, shared and defined procedures are lacking as Decision 242/2019 merely added some principles on which the legislature will have to base its future intervention. This paper analyses the advisory role that the Decision attributes to territorial ethics committees with the aim of stimulating discussions on their role in oversight mechanisms. The proposed conclusion is that the envisaged role does not appear consistent with the functions of these bodies and is ultimately substantially undefined and unjustified., (© 2023. The Author(s).)

Introduction: The situation in France is unique, having a legal framework for continuous and deep sedation (CDS). However, its use in intensive care units (ICU), combined with the withdrawal of life-sustaining therapies, still raises ethical issues, particularly its potential to hasten death. The legalization of assistance in dying, i.e., assisted suicide or euthanasia at the patient's request, is currently under discussion in France. The objectives of this national survey were first, to assess whether ICU professionals perceive CDS administered to ICU patients as a practice that hastens death, in addition to relieving unbearable suffering, and second, to assess ICU professionals' perceptions of assistance in dying., Methods: A national survey with online questionnaires for ICU physicians and nursesaddressed through the French Society of Anesthesiology and Critical Care Medicine., Results: A total of 956 ICU professionals responded to the survey (38% physicians and 62% nurses). Of these, 22% of physicians and 12% of nurses (p < 0.001) felt that the purpose of CDS was to hasten death. For 20% of physicians, CDS combined with terminal extubation was considered an assistance in dying. For 52% of ICU professionals, the current framework did not sufficiently cover the range of situations that occur in the ICU. A favorable opinion on the potential legalization of assistance in dying was observed in 83% of nurses and 71% of physicians (p < 0.001), with no preference between assisted suicide and euthanasia., Conclusion: Our findings highlight the tension between CDS and assisted suicide/euthanasia in the specific context of intensive care and suggest that ICU professionals would be supportive of a legislative evolution., (Copyright © 2023. Published by Elsevier Masson SAS.)

We would like to respond to the article "Organ donation after euthanasia starting at home in a patient with multiple system atrophy Tajaâte et al., [2021] 22:120" on organ donation after euthanasia from home [ODEH]. Although we welcome the performance of ODEH, we would like to make some critical comments regarding the article, both in relation to factual inaccuracies and in terms of the vision expressed on this subject. In this letter we stress the protection of autonomy of vulnerable euthanasia patients, we contradict the assumption of illegality, we question if the anesthesia method utilized is optimal and correct a mistake in regard to an article to which is referred of ourselves., (© 2023. The Author(s).)

The practice of euthanasia in The Netherlands shows a gradual widening of patient categories who are considered to be eligible. The latest addition to this list consists of patients with dementia who are no longer mentally competent. They too may obtain euthanasia if they provided an Advance Euthanasia Directive stating their wish, at a time when they still were mentally competent. This possibility is explicitly mentioned in the law. A recent judgment by the Dutch Supreme Court upheld the action of a doctor who performed euthanasia under such circumstances. Dutch doctors tended to ignore this possibility, because it would lead to euthanasing persons who do not realize what is being done to them. The issue was explored in a survey amongst 422 Dutch GP's. A surprising 45,7% of doctors thinks it is acceptable if midazolam is administered in order to forego unworthy scenes at the time of the actual euthanasia. The author disapproves of these developments.

Aim: This article outlines the End of Life Choice Act 2019. It highlights some of the key implementation issues to ensure the system operates safely and equitably after the Act comes into force. It also identifies priorities for research to ensure issues are detected and provision of assisted dying (AD) is monitored., Method: We reviewed the End of Life Choice Act, assisted dying implementation literature and governmental reports., Results: Effective system implementation depends on infrastructure, oversight and funding. In terms of service provision, we make recommendations about training for all health practitioners and providing practitioners; the nuances of discussing the "wish to hasten death"; conscientious objection; cultural safety for Māori; and minimising the complexity of delivering assisted dying practice. Structured research is needed to understand how the assisted dying system is operating., Conclusion: This article contributes by identifying core issues for practitioners, patients and policymakers. Implementation is an ongoing process that continues after the Act starts. Data are required to know whether access is equitable, who is choosing to make use of the law, whether providers are well informed and whether the safeguards are working as intended. The implications of how the Act is implemented are significant for patients, whānau, health professionals and society., Competing Interests: Jessica Young is the recipient of a Post-Doctoral Fellowship from the Cancer Society of New Zealand. Jessica Young is an appointed member of Support and Consultation for End of Life in New Zealand (SCENZ) Group. Jessica Young and Janine Winters are members of the Ministry of Health’s End of Life Choice Advisory network. Jessica Young, Colin Gavaghan and Andrew Geddis were members of the 2020 End of Life Choice Act Referendum Society/Yes for Compassion. Colin Gavaghan was an expert witness for the plaintiff in Seales v Attorney General. Ben White was engaged by the Victorian and Western Australian Governments to design and provide the legislatively mandated training for doctors involved in voluntary assisted dying in those states. Ben White also developed a model Bill for voluntary assisted dying for parliaments to consider. Ben White is a recipient of an Australian Research Council Future Fellowship (project number FT190100410: Enhancing End-of-Life Decision-Making: Optimal Regulation of Voluntary Assisted Dying) funded by the Australian Government.

Background: Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal., Methods: This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services., Results: So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low., Conclusions: Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.

A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these-epistemic indeterminacy and metaphysical indeterminacy-should be addressed in laws/policies regarding advance directives for euthanasia.

Physician-assisted suicide (PAS) and euthanasia can be debated from ethical and legal perspectives, and there are a variety of views regarding their acceptability and usefulness. Religion is considered an important factor in determining attitudes towards such practices. This narrative review aims to provide an overview of the Islamic perspective on PAS and euthanasia and explore the Islamic approach in addressing the related issues. The PubMed database was searched to retrieve relevant articles, then the references listed in the selected articles were checked for additional relevant publications. Additionally, religious books (Quran and hadith) and legal codes of selected countries were also consulted from appropriate websites. The Islamic code of law discusses many issues regarding life and death, as it considers any act of taking one's life to be forbidden. Islam sanctifies life and depicts it as a gift from God ( Allah ). It consistently emphasises the importance of preserving life and well-being. Therefore Muslims, the followers of Islam, have no right to end their life. All Islamic doctrines consider PAS and euthanasia to be forbidden. However, if the patient has an imminently fatal illness, withholding or withdrawing a futile medical treatment is considered permissible. From a legal perspective, Islamic countries have not legalised PAS and euthanasia. Such practices are therefore considered suicides when patients consent to the procedure, and homicides when physicians execute the procedure.

Aim: To provide an overview of the New Zealand End of Life Choice Act in comparison with other countries, arguments for and against euthanasia, and consideration of relevant legal and practical issues., Method: Structured descriptive summary of criteria for medical euthanasia in various jurisdictions currently allowing the practice, compared with New Zealand legislation. Narrative review of arguments for and against euthanasia with reference to existing medical literature and legal cases., Results: A strong case for medical assistance in dying, based on autonomy and quality of life arguments, is countered by a long history of medical and legal tradition protecting life., Conclusion: This highly contentious issue is coming before the New Zealand public as a referendum in October 2020. The results will have profound implications for medical practice as well as reflecting societal shifts in attitudes toward death and dying., Competing Interests: Nil.

Agency is the human capacity to freely choose one's thoughts, motivations and actions without undue internal or external influences; it is distinguished from decisional capacity. Four well-known conditions that can deeply affect agency are depression, demoralization, existential distress, and family dysfunction. The study reviews how they may diminish agency in persons whose circumstances may lead them to consider or request euthanasia or assisted suicide. Since agency has been a relatively neglected dimension of autonomous choice at the end of life, it is argued that to respect the autonomy of individuals, it is essential to establish their agency.

Objective: Analyse the evolution of opinions about euthanasia by the general public and clinical physicians from 1995 to 2019 and their influence at the present time., Material and Method: Bibliographical review based on relevance and quality of publications in open access and academic access platforms. Main surveys review of public and private institutions. Congress and Senate Official Journal Sessions., Results: Recent surveys show that clinicians support the regulation of euthanasia. This position matches the general public's belief, which has grown steadily in recent decades., Discussion: Social and clinical support for the regulation of euthanasia has been fundamental. In the last two decades political parties have changed their positions, thus creating a window of opportunity.

The paper presents an account of suffering as a multi-level phenomenon based on concepts such as mood, being-in-the-world and core life value. This phenomenological account will better allow us to evaluate the hardships associated with dying and thereby assist health care professionals in helping persons to die in the best possible manner. Suffering consists not only in physical pain but in being unable to do basic things that are considered to bestow meaning on one's life. The suffering can also be related to no longer being able to be the person one wants to be in the eyes of others, to losing one's dignity and identity. These three types of suffering become articulated by a narrative that holds together and bestows meaning on the whole life and identity of the dying person. In the encounter with the patient, the health-care professional attempts to understand the suffering-experience of the patient in an empathic and dialogic manner, in addition to exploring what has gone wrong in the patient's body. Matters of physician assisted suicide and/or euthanasia-if it should be legalized and if so under which conditions-need to be addressed by understanding the different levels of human suffering and its positive counterpart, human flourishing, rather than stressing the respect for patient autonomy and no-harm principles, only. In this phenomenological analysis the notions of vulnerability and togetherness, ultimately connecting to the political-philosophical issues of how we live together and take care of each other in a community, need to be scrutinized.

Of all medical procedures euthanasia is surely the most fearful, involving as it does the deliberate ending of a human life. Yet after 1975 there was growing unease about the medical treatment of dying patients, resulting in requests to stop useless treatments and end a patient's life as a way out of unbearable suffering. The actual practice of euthanasia went through many stages. The slippery slope question is very astute: over the years new groups of suffering persons emerged who considered themselves eligible. Next to terminal patients came patients with chronic diseases, psychiatric patients, people suffering from dementia in the early stages, and dementia in the later stages. In spite of many misgivings, there is the fact that for the first time in history people have the possibility to leave life when it has become unbearable, in open communication with their loved ones.

For many yearsthere has been confusion in the Netherlands about the question of whether doctors are entitled to end the life of incompetent patients with advanced dementia. The euthanasia control commission, the disciplinary courts and the penal court all answered this question differently after a doctor had performed euthanasia on a 74-year-old woman with advanced dementia and an advance directive made at an earlier stage. On 21 April 2020 the Supreme Court provided clarity, at least to a certain extent. This contribution presents an analysis of the decisions made by the Supreme Court and their implications for self-chosen death in patients with advanced dementia.

Euthanasia is legal in the Netherlands. Nevertheless, some individuals decide to plan their self-chosen death without the help of a physician. 'Right-to-die' organisations provide advice about humane deaths, which include voluntary refusal of food and fluids, the helium method and use of a lethal overdose of medication. It is known that suicides are sometimes influenced by the media and internet. Since 2013, 'right-to-die' organisations have informed individuals about the use of a deadly barbiturate overdose and the helium method. A rise in suicides resulting from these methods has subsequently been observed in the Netherlands. Suicides are recorded as deaths resulting from unnatural causes and are therefore investigated by a forensic physician, forensic investigator and tactical investigator. Investigation should determine the cause of death and rule out a staged crime, 'criminal' assisted suicide or an accident.

Background: Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research., Methods: Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis., Results: We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians., Conclusions: The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Laws against wrongdoing may originate in justice intuitions that are part of universal human nature, according to the adaptationist theory of the origins of criminal law. This theory proposes that laws can be traced to neurocognitive mechanisms and ancestral selection pressures. According to this theory, laypeople can intuitively recreate the laws of familiar and unfamiliar cultures, even when they lack the relevant explicit knowledge. Here, to evaluate this prediction, we conduct experiments with Chinese and Sumerian laws that are millennia old; stimuli that preserve in fossil-like form the legal thinking of ancient lawmakers. We show that laypeople's justice intuitions closely match the logic and content of those archaic laws. We also show covariation across different types of justice intuitions: interpersonal devaluation of offenders, judgements of moral wrongness, mock-legislated punishments and perpetrator shame-suggesting that multiple justice intuitions may be regulated by a common social-evaluative psychology. Although alternative explanations of these findings are possible, we argue that they are consistent with the assumption that the origin of criminal law is a cognitively sophisticated human nature.

End-of-life decision-making in patients with dementia is a complex topic. Belgium and the Netherlands have been at the forefront of legislative advancement and progressive societal changes concerning the perspectives toward physician-assisted death (PAD). Careful consideration of clinical and social aspects is essential during the end-of-life decision-making process in patients with dementia. Geriatric assent provides the physician, the patient and his family the opportunity to end life with dignity. Unbearable suffering, decisional competence, and awareness of memory deficits are among the clinical considerations that physicians should incorporate during the end-of-life decision-making process. However, as other societies introduce legislature granting the right of PAD, new social determinants should be considered; Mexico City is an example. Current perspectives regarding advance euthanasia directives (AED) and PAD in patients with dementia are evolving. A new perspective that hinges on the role of the family and geriatric assent should help culturally heterogeneous societies in the transition of their public health care policies regarding end-of-life choices.

In light of recent media coverage, Emeritus Professor Alan Glasper , from the University of Southampton, discusses polices and guidance that relate to euthanasia and assisted suicide.

Objective: Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legalised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that currently have legalised this. In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revision of legislation or changes in practice., Conclusions: We suggest that this dynamic can be halted by international agreements of medical societies to shun involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have in the past, need to work collectively to meet this ethical challenge.

Objective: To describe the characteristics of persons with dementia receiving euthanasia/assisted suicide (EAS) and how the practice is regulated in the Netherlands., Designs: Qualitative directed content analysis of dementia EAS reports published by the Dutch euthanasia review committees between 2011 and October 5, 2018., Results: Seventy-five cases were reviewed: 59 concurrent requests and 16 advance requests. Fifty-three percent (40/75) were women, and 48% (36/75) had Alzheimer disease. Advance request EAS patients were younger, had dementia longer, and more frequently had personal experience with dementia. Some concurrent request EAS patients were quite impaired: 15% (9/59) were deemed incompetent by at least one physician; in 24% (14/59), patients' previous statements or current body language were used to assess competence. In 39% (29/75), patients' own physicians declined to perform EAS; in 43% (32/75), the physician performing EAS was new to them. Physicians disagreed about patients' eligibility in 21% (16/75). All advance request and 14 (25%) concurrent request patients had an advance euthanasia directive but the conditions of applicability often lacked specificity. In 5 of 16 advance request EAS and 2 of 56 concurrent request EAS cases, EAS procedure was modified (e.g., premedication). Twenty-five percent (4/16) of advance request cases did not meet legal due care criteria, in particular the "unbearable suffering" criterion., Conclusions: Advance and concurrent request EAS cases differ in age, duration of illness, and past experience. Advance request EAS cases were complicated by ambiguous directives, patients being unaware of the EAS procedure, and physicians' difficulty assessing "unbearable suffering." Notably, some concurrent request patients were quite impaired yet deemed competent by appeals to previous statements., (Published by Elsevier Inc.)

Background: Euthanasia and assisted suicide laws in the Netherlands require physicians meet clinical guidelines when performing the practice to ensure death is peaceful and painless. Despite oversight by the regional review committees over each case, little research exists into the frequency of guideline deviation and the reasons for nonadherence., Methods: Cases reported and reviewed between 2012 and 2017 that did not meet due medical care were analysed for thematic content. Semistructured interviews were conducted with 11 Dutch physicians on their experience with the clinical and pharmacological elements of euthanasia and assisted suicide, their interaction and comportment with the recommended guidelines, and reasons why guideline deviation might occur. Reported case reviews and interviews were used to obtain themes and subthemes to understand how and why deviations from clinical guidelines happened., Results: Violations of due medical care were found in 42 (0.07%) of reported cases. The regional review committees found physicians in violation of due medical care mostly for inadequate confirmation of coma-induction and deviations from recommended drug dosages. Physicians reported that they rarely deviated from the guidelines, with the most common reasons being concern for the patient's family, concern over the drug efficacy, mistrust in the provided guidelines, or relying on the poor advice of pharmacists or hospital administrators., Conclusions: Deviations from the guidelines and violations of due medical care are rare, but should nonetheless be monitored and prevented. A few areas for improvement include skills training for physicians, consistency between review committee rulings, and further clarity on dosage recommendations., (© The Author(s) 2019. Published by Oxford University Press.)

Background: Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient-clinician interactions, both of which could complicate EAS evaluations., Methods: We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017)., Results: Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present., Conclusions: The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.

Euthanasia and medical assistance in dying entail daunting ethical and moral challenges, in addition to a host of medical and clinical issues, which are further complicated in cases of patients whose decision-making skills have been negatively affected or even impaired by psychiatric disorders. The authors closely focus on clinical depression and relevant European laws that have over the years set firm standards in such a complex field. Pertaining to the mental health realm specifically, patients are required to undergo a mental competence assessment in order to request aid in dying. The way psychiatrists deal and interact with decisionally capable patients who have decided to end their own lives, on account of sufferings which they find to be unbearable, may be influenced by subjective elements such as ethical and cultural biases on the part of the doctors involved. Moreover, critics of medical aid in dying claim that acceptance of such practices might gradually lead to the acceptance or practice of involuntary euthanasia for those deemed to be nothing more than a burden to society, a concept currently unacceptable to the vast majority of observers. Ultimately, the authors conclude, the key role of clinicians should be to provide alternatives to those who feel so hopeless as to request assistance in dying, through palliative care and effective social and health care policies for the weakest among patients: lonely, depressed or ill-advised people.

In this article we critically evaluate an argument against state-sanctioned euthanasia made by David Velleman in his 1992 paper 'Against the right to die'. In that article, Velleman argues that legalizing euthanasia is morally problematic as it will deprive eligible patients of the opportunity of staying 'alive by default'. That is to say, those patients who are rendered eligible for euthanasia as a result of legislative reform will face the burden of having to justify their continued existence to their epistemic peers if they are to be perceived as 'reasonable'. We discuss potential criticisms that could be made of the argument, and consider how a defender of the view might respond. Velleman's argument is particularly interesting as it is a consequentialist argument against state-sanctioned euthanasia, challenging the many consequentialist arguments that have been made in favour of legalizing the procedure. We conclude by suggesting that further research on the question of unfair burdens is important to adequately evaluating the potential harms of legalizing euthanasia for patients at the end of life., (© 2019 John Wiley & Sons Ltd.)

Background: Medical Assistance in Dying, also known as euthanasia or assisted suicide, is expanding internationally. Canada is the first country to permit Nurse Practitioners to provide euthanasia. These developments highlight the need for nurses to reflect upon the moral and ethical issues that euthanasia presents for nursing practice., Purpose: The purpose of this article is to provide a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice., Methods: Systematic search and narrative review. Nine electronic databases were searched using vocabulary developed from a stage 1 search of Medline and CINAHL. Articles that analysed a focused ethical question related to euthanasia in the context of nursing practice were included. Articles were synthesized to provide an overview of the literature of nursing ethics and euthanasia., Ethical Considerations: This review was conducted as per established scientific guidelines. We have tried to be fair and respectful to the authors discussed., Findings: Forty-three articles were identified and arranged inductively into four themes: arguments from the nature of nursing; arguments from ethical principles, concepts and theories; arguments for moral consistency; and arguments from the nature of the social good. Key considerations included nursing's moral ontology, the nurse-patient relationship, potential impact on the profession, ethical principles and theories, moral culpability for acts versus omissions, the role of intention and the nature of the society in which euthanasia would be enacted. In many cases, the same assumptions, values, principles and theories were used to argue both for and against euthanasia., Discussion: The review identified a relative paucity of literature in light of the expansion of euthanasia internationally. However, the literature provided a fulsome range of positions for nurses to consider as they reflect on their own participation in euthanasia. Many of the arguments reviewed were not nursing-specific, but rather are relevant across healthcare disciplines. Arguments explicitly grounded within the nature of nursing and nurse-patient relationships warrant further exploration.

On 11 September 2019, the verdict was read in the first prosecution of a doctor for euthanasia since the Termination of Life on Request and Assisted Suicide (Review Procedures) Act of 2002 was installed in the Netherlands. The case concerned euthanasia on the basis of an advance euthanasia directive (AED) for a patient with severe dementia. In this paper we describe the review process for euthanasia cases in the Netherlands. Then we describe the case in detail, the judgement of the Regional Review Committees for Termination of Life on Request and Euthanasia (RTE) and the judgement of the medical disciplinary court. Both the review committees and the disciplinary court came to the conclusion there were concerns with this case, which mainly hinged on the wording of the AED. They also addressed the lack of communication with the patient, the absence of oral confirmation of the wish to die and the fact that the euthanasia was performed without the patient being aware of this. However, the doctor was acquitted by the criminal court as the court found she had in fact met all due care criteria laid down in the act. We then describe what this judgement means for euthanasia in the Netherlands. It clarifies the power and reach of AEDs, it allows taking conversations with physicians and the testimony of the family into account when interpreting the AED. However, as a practical consequence the prosecution of this physician has led to fear among doctors about prosecution after euthanasia., Competing Interests: Competing interests: ECAA and SvdV receive funding from the Dutch Association for Voluntary End of Life (NVVE)., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

The arguments for and against euthanasia present a complex picture that will need to be discussed and decided in Mexico. This article addresses some relevant aspects such as the legal determination of death, the field of bioethics intervention, terminology related to euthanasia, its classifications, international instruments promoting human rights, as well as reflections on the importance of palliative care and the patient's right to be in a terminal situation to act in accordance with their goals, expectations and beliefs, in the context of their family and social relationships., (Copyright: © 2020 Permanyer.)

Objectives: To describe and compare euthanasia and physician-assisted suicide (EAS) practice in Flanders, Belgium (BE), the Netherlands (NL) and Switzerland (CH)., Methods: Mortality follow-back surveys among attending physicians of a random sample of death certificates., Results: We studied 349 EAS deaths in BE (4.6% of all deaths), 851 in NL (4.6% of all deaths) and 65 in CH (1.4% of all deaths). People who died by EAS were mostly aged 65 or older (BE: 81%, NL: 77% and CH: 71%) and were mostly diagnosed with cancer (BE: 57% and NL: 66%). Home was the most common place of death in NL (79%), while in BE and CH, more variation was found regarding to place of death. The decision to perform EAS was more frequently discussed with a colleague physician in BE (93%) and NL (90%) than in CH (60%)., Conclusions: EAS practice characteristics vary considerably in the studied countries with legal EAS. In addition to the legal context, cultural factors as well as the manner in which legislation is implemented play a role in how EAS legislation translates into practice.

The purpose of this article is to analyze the main medical, legal, and ethical issues and challenges of euthanasia in the digital age. The methods that were used in this study are historical, logical, empirical, as well as comparative legal method for comparison of laws and practices of the EU and post-Soviet countries, including Ukraine. This choice determined by the fact that both groups of countries have common features and relations, while the features of their development affect approaches to regulating such sensitive and potentially open to abuse problems as euthanasia. There is no final legal answer as to whether to legalize, decriminalize or prohibit euthanasia in any of its forms. The features and legal terms of active and passive, voluntary and non-voluntary euthanasia and assisted suicide, especially for psychiatric and minor patients were researched, as well as conflicting arguments, which include individual autonomy, right to choose, the opportunity to get rid of suffering, as well as undermining the practice of palliative care, abuse in cases of vulnerable and dependent patients, moral burden on the doctors. The issue of control of the practice of euthanasia is complicated, given the extent to which it is possible to obtain informed consent, establish criteria for suffering and hopelessness, check the persistence, conviction and validity of requests for euthanasia, especially in the digital era. The potential legislation and judicial practice should provide for strict and effective guarantees, respect for the beliefs of each person and the right not to participate in any contentious practices, the balance of human rights and social values.