Comment fait-on le choix de l'euthanasie ? A quel moment en prend-on la décision ? Faut-il un courage héroïque pour aller au-devant de la mort, la souhaiter, la programmer ? Comment, alors, la famille parvient-elle à accepter un tel choix ? Un récit sans tabou, qui relate les ultimes étapes d'une vie devenue invivable. Mais aussi une déclaration d'amour à l'être aimé et à la vie.
Militante pour un droit à une fin de vie digne et apaisée, l'auteure apporte un éclairage juridique sur la question et s'interroge sur l'existence d'une liberté et d'un droit à mourir. Elle illustre son propos d'exemples tirés du droit comparé.
CONTEXT: It is crucial that physicians understand differing attitudes towards euthanasia and which factors to consider when discussing end-of-life decisions with patients and families from diverse backgrounds.
OBJECTIVES: To investigate how attitudes towards euthanasia differ among countries, how they change, and how economic, religious, and health-related factors affect these attitudes.
METHODS: We analyzed attitudes towards euthanasia and economic, religious, and health-related indicators using longitudinal (1981-2018) World Values Survey (WVS) data. They included 62 countries with at least a 15-year, three-wave, time series (total n=389,243 participants). Each national survey interviewed representative samples of adults (mean=1,405).
RESULTS: In the latest wave, The Netherlands had the most favorable views of euthanasia (10-point scale with 1=least justifiable: Mean=7.47) and Jordan the least (Mean=1.50). Residents of 23 of 24 high-income countries came to view euthanasia as more justifiable, while residents of 12 of 38 middle- and low-income countries came to view it as less justifiable over time. The higher GDP per-capita at the time of survey, the more euthanasia was accepted (r=0.703; p<0.0001); the more important respondents viewed religion as being, the less euthanasia was accepted (r= -0.834; p<0.0001); the higher life expectancy and the lower infant mortality were, the more euthanasia was accepted (r=0.669; p<0.0001/r=-0.716; p<0.0001).
CONCLUSION: Euthanasia-related attitudes differ widely depending on the cultural context; changes over time varied in both directions; euthanasia-related attitudes were associated with economic, religious and health-related factors. With globalization increasing cultural diversity, these findings can inform physicians' communication about end-of-life decisions with patients and families from diverse backgrounds.
In 2002 with the passing of the Euthanasia Law, Belgium became one of the few countries worldwide to legalize euthanasia. In the 18 years since the passing of the law, much has changed. We argue that in Belgium a widening of the use of euthanasia is occurring and that this can be ethically and legally problematic. This is in part related to the fact that several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such. We focus on three kinds of safeguards or procedural guarantees: (1) the legally defined due care criteria for eligibility for euthanasia; (2) the consultation of a second (and sometimes third) physician; and (3) the reporting of euthanasia cases to the Federal Control and Evaluation Commission for Euthanasia. We will show how each of these three safeguards can exhibit shortcomings in theory and practice.
The number of psychiatric patients requesting Euthanasia or Assisted Suicide (EAS) continues to increase. The aims of this systematic review were to: 1) describe the available data related to psychiatric patients having received or requesting EAS (pEAS) for each country in which is allowed; 2) and describe the ethically salient points that arise. PubMed, PsycINFO, and Scopus databases were searched to identify articles published up to September 2020. Among the retrieved publications, only studies on pEAS cases (pEAS-C), pEAS requests, or physician reports/attitude towards pEAS reporting some quantitative data on patients having received or requesting pEAS were retained. Among the 24 included studies, thirteen (54%) were about pEAS in the Netherlands, four (17%) in Belgium, and seven (29%) in Switzerland. Results were different across different countries. In the Netherlands, pEAS-C were mostly women (70-77%) and often had at least two psychiatric disorders (56-97%). Mood disorders were mainly represented (55-70%) together with personality disorders (52-54%). History of suicide attempts was present in 34-52%. Moreover, 37-62% of them had at least one comorbid medical condition. In Belgium pEAS-C were mostly women (75%), but the majority (71%) had a single diagnosis, mood disorder. In Switzerland available data were less detailed. As pEAS-C seem to be very similar to 'traditional suicides', pEAS procedures should be carefully revised to establish specific criteria of access and guidelines of evaluation of the request. A deeper focus on unbearable suffering, decision capacity and possibilities of improvements is warranted as well as the involvement of mental health professionals.
A l’heure où les techniques médicales prolongent la vie en questionnant sur sa qualité et où l’idéal de liberté et d’autonomie individuelles se heurte aux logiques de contrôle politique et médical de la vie, la question de l’aide à mourir prend une place centrale dans les débats sur la fin de vie. La Belgique, qui depuis plus de 17 ans bénéficie d’une loi de dépénalisation de l’euthanasie, constitue un observatoire privilégié pour comprendre les enjeux de cette pratique et permet plus largement de questionner une certaine construction de la bonne mort en lien avec les problématiques que révèle l’avancée en âge. Quelles sont les relations entre le grand âge et la pratique de l’euthanasie ? Les personnes âgées en sont-elles des usagers comme les autres ? Que nous disent les parcours euthanasiques sur ce qui, dans le grand âge, constitue un invivable ? Les données récoltées lors d’une enquête ethnographique menée à Bruxelles auprès des différents acteurs de la pratique de l’euthanasie mettent en lumière la manière dont ce processus s’inscrit dans des logiques sociales où s’articulent les notions d’autonomie et de dignité, de dépendance interpersonnelle et de liberté individuelle. Examiner le recours à l’aide à mourir dans le grand âge nous amène à explorer une fabrique contemporaine de la bonne mort et à dessiner les contours de ce qui, dans les sociétés occidentales, balise aujourd’hui la vie bonne.
BACKGROUND: The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.
OBJECTIVES: This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013-2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.
DESIGN, SETTING AND METHODS: This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.
RESULTS: There is considerable variation in euthanasia ratio. Throughout the years (2013-2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.
CONCLUSION: The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.
Amongst other countries, the Netherlands currently allows euthanasia, provided the physician performing the procedure adheres to a strict set of requirements. In 2016, Second Chamber member Pia Dijkstra submitted a law proposal which would also allow euthanasia without the reason necessarily having any medical foundation; euthanasia on the basis of a completed life. The debate on this topic has been ongoing for over two decades, but this law proposal has made the discussion much more immediate and concrete. This paper considers the moral permissibility of Pia Dijkstra's law proposal, focusing on the ethics of the implementation Dijkstra describes in her proposal. I argue that, at present, Dijkstra's law proposal is unsuitable for implementation, due to a number of as of yet unaddressed problems, including the possible development of an ageist stigma and undue pressure on the profession of end-of-life coordinator. Perhaps adequate responses can be conceived to address these issues. However, the existence of a radically different, yet currently equally unacceptable position regarding the implementation of euthanasia for a completed life as proposed by fellow party member Paul Schnabel suggests it may be difficult to formulate an ethically acceptable implementation for this, in principle, ethically acceptable concept.
Objectives: To explore the legal understanding and attitudes of nurses and physicians in both acute and chronic geriatric care (Flanders, Belgium) regarding euthanasia in the context of tiredness of life in older people.
Method: Healthcare providers employed in acute care (59 geriatricians and 75 nurses of acute geriatric wards), as well as chronic care (135 general practitioners (GPs) and 76 nurses employed in nursing homes and home care services) were sent a survey with four case vignettes. For each case vignette, respondents were asked the following questions: (1) ‘Does this case fit the due-care criteria of the euthanasia law?’, (2) ‘Do you consider this person to be tired of life?’, (3) ‘Can you comprehend this person’s euthanasia request?’.
Results: In cases of severe and life-limiting physical suffering, where the patient meets the legal criteria for euthanasia in Belgium, only 50% of physicians and nurses are aware of this legal basis. In case of tiredness of life without underlying pathology, nurses showed more comprehension for the euthanasia request compared to physicians (43.0% vs. 10.8%, p < 0.001). Physicians tend to assess the legal base of an euthanasia-request depending on the severity of physical morbidity, whereas nurses show a greater comprehension towards euthanasia-requests even in absence of severe illness. Geriatricians are more reserved regarding performing euthanasia themselves as compared to GPs, regardless of underlying pathology or reason for the euthanasia-request (p < 0.001).
Conclusion: The legal understanding and attitude of Flemish physicians and nurses towards tiredness of life and euthanasia in older patients differed to a great extent. This study showed (1) a lack of awareness of the legal basis for euthanasia in the context of ToL among all HCPs, (2) differences in the extent of comprehension between nurses and physicians and (3) differences in willingness to actually perform euthanasia between geriatricians and GPs. So even with the formulation of strict due-care criteria there is still room for interpretation. This creates a gray area and a discussion point between healthcare providers.
Purpose: The purpose of this study was to explore knowledge and attitudes of health program students towards ethical issues pertaining to the beginning and the end of human life, and associations between these attitudes and demographic variables.
Participants and Methods: The study took a mixed-method approach with self-administered survey questionnaires and in-depth interviews. A total of 88 students participated in the survey, and 10 students participated in interviews. The study was conducted among students in the Health Extension Program at a Christian university in Papua New Guinea.
Results: Students showed a higher acceptance of abortion than euthanasia. More year-4 students presented significantly deeper knowledge of euthanasia and abortion compared to year-1 students. There were no gender differences regarding knowledge and attitude towards these two bioethical issues. The majority of students opposed the idea of women's right to abortion, which is attributed mainly to socio-cultural reasons. The qualitative analysis indicated a very strong perception that having children 'defines' womanhood and also revealed general disapproval of any form of euthanasia. A low level of acceptance of various forms of euthanasia is associated with a respect for older people in Melanesian society and beliefs that ancestors' support is required for achieving prosperity in life.
Conclusion: The study offered a comprehensive description and analysis of students' knowledge and attitudes towards ethical issues pertaining to the beginning and the end of human life. Presented a low level of knowledge towards bioethical issues, together with a small proportion of the knowledge gained from lectures and tutorials, indicated inadequate teaching of bioethics and calls for further improvement. In the perspective of rapid social and cultural changes in the Papua New Guinea society, further studies on changing attitudes towards bioethics issues would be valuable.
Euthanasia and physician assisted suicide (E/PAS) in the context of unbearable psychological or emotional suffering related to psychiatric disorders (psychiatric E/PAS) is ahighly debated topic. In Belgium and The Netherlands, the law allows for psychiatric E/PAS since 2002. The aim of this article is to give an overview of the Belgian and Dutch experiences and the questions raised during the last decade of real-life experiences with psychiatric E/PAS. We use the available national data on psychiatric E/PAS to present a quantitative overview of the current situation. In addition, we identified different challenges; i.e. ethical, medicalpsychiatric and legal, that increasingly impact and change the attitudes within the medical and psychiatric professional community towards psychiatric E/PAS.
We examine and integrate last two decades of research on euthanasia from a cultural perspective. After an exhaustive search from Scopus and Web of Science, 40 studies matching our criteria are included in the review. We qualitatively summarize the literature country-wise and use text map of co-occurring terms in the titles, keywords, and abstracts of these articles to determine the similarities and differences among sub-themes in continental clusters. Research done in Asian, European, North American, and multi-cultural studies suggests that attributes unique to each culture are instrumental in shaping public attitudes towards euthanasia. We also find that some cultures, despite the prevalence of euthanasia, are underrepresented in empirical research. This review of literature on the cultural nuances in end-of-life decisions such as euthanasia is pertinent to social scientists, healthcare professionals and social workers in any given time, but more so during such critical events as worldwide COVID-19 pandemic.
OBJECTIVE: Studies in countries where assisted dying is legal show that bereaved people express concern over the potential for social disapproval and social stigma because of the manner of death. There are indications that voluntary assisted dying is judged as less acceptable if the deceased is younger. A vignette-based experiment was used to determine whether public stigma (i.e., negative emotional reactions and desired social distance) and expected grief symptoms are higher for conjugally bereaved people through voluntary assisted dying (vs. long-term illness), when the deceased is a young adult (vs. older adult).
METHOD: A 2 × 2 randomized factorial design was conducted with 164 Australian adults (130 women, 34 men, Mage = 37.69 years). Each participant was randomized online to read one of four vignettes and completed measures of anger, fear, prosocial emotions, desire for social distance, and expectations of grief symptomatology.
RESULTS: A multivariate analysis of variance (MANOVA) was conducted. Death at a young age (28 years) was significantly associated with stronger negative emotional reactions of fear ($\eta _p^2 = 0.04$, P = 0.048) and anger ($\eta _p^2 = 0.06$, P = 0.010). There were no differences in outcomes associated with the mode of death, nor was there an interaction between mode of death and age group.
SIGNIFICANCE OF RESULTS: Concerns that voluntary assisted dying elicits public stigma appear unfounded. The fact that participants reported significantly higher anger and fear in response to bereaved people experiencing loss at a younger (vs. older) age, irrespective of cause of death, indicates that young people who lose their spouse might benefit from additional support.
In 2002, the Dutch Euthanasia Act was put in place to regulate the ending of one's life, permitting a physician to provide assistance in dying to a patient whose suffering the physician assesses as unbearable. Currently, a debate in the Netherlands concerns whether healthy (older) people who value their life as completed should have access to assistance in dying based on their autonomous decision making. Although in European law a right to self-determination ensues from everyone's right to private life, the Dutch Supreme Court recently adopted a position on whether the Dutch Euthanasia Act lacks adequate attention to a patient's autonomous decision making. Specifically, in the Albert Heringa case, the Court ruled that the patient-physician relationship as understood in the Dutch Euthanasia Act limits this plea for more self-determination. This ethical analysis of the Heringa case examines how the Supreme Court's understanding of the Euthanasia Act defines patient autonomy within a reciprocal patient-physician relationship.
Alors que la mort des personnes âgées a connu en 2020 une exposition médiatique certaine du fait de la crise de la Covid 19, il n'en demeure pas moins difficile de penser la fin de vie et la mort au grand âge sans préjugés.
L'objectif de ce numéro est d'aller au-delà des prêt-à-penser de sens commun pour s'appuyer sur des articles de chercheurs et de soignants qui se sont efforcés de décrire, analyser et rendre compte de la manière dont se déroulent différentes formes de fins de vies au grand âge. Ces éclairages permettent de comprendre quels sont les enjeux concrets de ces fins de vies que ne peuvent résoudre simplement une évocation du droit, des procédures standardisées de soin et moins encore des idéologies ou des concepts qui ne seraient pas ancrées dans les réalités vécues par les personnes et leur entourage proche ou professionnel. La dimension internationale de ce numéro permet également de saisir le poids des contextes politiques et socioculturels sur l'administration des fins de vie dans l'âge avancé.
Le titre que nous avons donné à ce numéro « finir sa vie, hâter la mort » constitue une illustration des trois axes que comptent ce numéro avec des articles abordant l'accompagnement et les parcours de fin de vie des personnes âgées, d'autres qui interrogent les procédures d'euthanasie et de suicide assisté au grand âge et enfin des articles qui mettent en question les différentes formes de constructions, normalisations et pathologisations de la mort au grand âge.
Importance: The Dutch Regional Euthanasia Review Committees (RTEs) reviewed and reported an increasing number of cases of euthanasia and physician-assisted suicide (EAS) requested by older people with multiple geriatric syndromes (MGS). Knowledge of the characteristics of cases of EAS for MGS is important to facilitate societal debate and to monitor EAS practice.
Objective: To examine the accumulation of patient characteristics, geriatric syndromes, and other circumstances as reported in the case summaries of the RTEs that led to unbearable suffering associated with a request for EAS and to analyze the RTEs' assessments of these cases of EAS.
Design, Setting, and Participants: A qualitative content analysis was conducted of all case summaries filed from January 1, 2013, to December 31, 2019, under the category MGS and published in a national open access database. These case summaries were selected by the RTEs from the total of 1605 reported cases of EAS in the category MGS.
Results: The RTEs published 53 cases (41 [77%] female) under the category MGS. A total of 28 patients (53%) had always perceived themselves as independent, active, and socially involved. None of the patients suffered from life-threatening conditions. Multiple geriatric syndromes, such as visual impairment (34 cases [64%]), hearing loss (28 cases [53%]), pain (25 cases [47%]), and chronic tiredness (22 cases [42%]), were common. The request for EAS was often preceded by a sequence of events, especially recurrent falls (33 cases [62%]). Although physical suffering could be determined in all cases, the case descriptions found that suffering occurred on multiple dimensions, such as the loss of mobility (44 [83%]), fears (21 [40%]), dependence (23 [43%]), and social isolation (19 [36%]).
Conclusions and Relevance: This qualitative study suggests that an accumulation of geriatric syndromes leading to a request for EAS is often intertwined with the social and existential dimension of suffering. This leads to a complex interplay of physical, psychological, and existential suffering that changes over time.
BACKGROUND: An increasing number of jurisdictions around the world are legalizing assisted dying. This creates a particular challenge for the field of palliative care, which often precludes producing premature death by the injection or self-administration of lethal medications upon a patient's voluntary request. A 2019 systematic scoping review of the literature about the relationship between palliative care and assisted dying in contexts where assisted dying is lawful, found just 16 relevant studies that included varied and combined stances ranging from complete opposition, to collaboration and integration. Building on that review, the present study was conducted in Quebec (Canada), Flanders (Belgium), and Oregon (USA), with the objective of exploring the relationship between palliative care and assisted dying in these settings, from the perspective of clinicians and other professionals involved in the practice.
METHODS: Semi-structured in-depth qualitative interviews were conducted with 29 professionals from Oregon , Quebec  and Flanders . Participants were involved in the development of policy, management, or delivery of end of life care services in each of the jurisdictions. Data was analyzed thematically and followed a procedure of data immersion, and the construction of a thematic and interpretive account.
RESULTS: Three themes were identified from each of the locations. Flanders: the integrated approach; discontents in palliative care; concerns about liberalization of assisted dying laws. Oregon: the role of hospice; non-standardized protocols and policies; concerns about access to medications and care. Quebec: a contested relationship; the special situation of independent hospice; lack of knowledge about and access to palliative care.
CONCLUSIONS: No clear and uniform relationship between palliative care and assisted dying can be identified in any of the three locations. The context and practicalities of how assisted dying is being implemented alongside access to palliative care need to be considered to inform future laws. We seek a better understanding of whether and in what ways assisted dying presents a threat to palliative care.