On 16 November , the Italian Constitutional Court addressed for the first time the controversial issue of the constitutionality of the criminalisation of assisted suicide of patients suffering from serious and incurable diseases. In its judgment, the Court held that the crim-inalisation of assisted suicide is not contrary to the Constitution, rejecting the existence of a right to die, in line with the European Court of Human Rights case law. Nevertheless, the Constitutional Court recognised that in cases of patients suffering from serious and incurable diseases, an absolute prohibition on assisted suicide could run contrary to the freedom of self-determination and the constitutional principles of human dignity and equality.
The present note describes and analyses the facts of the case and the reasoning of the Constitutional Court, especially the structure of the argument and the new 'decision technique' adopted. Power and the Glory VI. The battle with Catholicism is not ultimately between political-social-economic ideas. The Indians, peons, and the people en mass reopened the churches and forced the state to allow the return of bishops and priests. That Greene is attacking the whole modern project which ties technology to science for the entire elimination of pain, because pain has no religious, theological, philosophical justification appears with the dentist, with whom, I repeat, The Power and the Glory opens.
George Grant in Time as History most useful reading to prepare for both The Power and the Glory and The Mountain and the Valley writes: The last men are those who have inherited the ideas of happiness and equality from the doctrine of progress. But because this happiness is to be realized by all men, the conception of its content has to be shrunk to fit what can be realized by all. And a lot of poison at the last, for a pleasant death. Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?
Advocates of physician-assisted suicide PAS often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions Advocates of physician-assisted suicide PAS often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions.
In this paper, I address three arguments of this sort. Firstly, that psychiatric conditions compromise a person's decision-making capacity. Secondly, that we cannot have sufficient certainty that a person's psychiatric condition is untreatable. Thirdly, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable.
Recht am Ende des Lebens Perspectives of law and culture on the end-of-life legislations in. The discourse on this issue should be multidisciplinary, taking into account its legal, medical, ethical, philosophical and anthropological aspects. The concepts designed to manage the legal problems that occur when a life comes to an end are closely linked to the culture of each country. For this reason, countries with different cultural backgrounds have been selected for this comparative end-of-life study.
In France, Germany and Italy, which have a continental legal system, the United Kingdom, which has a common law system, and India, the various religions and cultures exert an important influence on the modernization of the legislation in this respect. The book deals with recent legislative changes and developments in the countries surveyed. Un confronto tra Italia e Inghilterra. To suffer the most serious damage of these attitudes are the sick, who in this matter more than ever need cer- tainty to the law.
The world today is faced with the problem of cases of suicide; I present in this paper a moral, ethical and theological conjecture on Suicide. Suicide is one of the most difficult experiences that face humanity and most of all so hard to Suicide is one of the most difficult experiences that face humanity and most of all so hard to believe or understand why people choose suicide as an option to enter eternity. Various surveys have been carried out to determine what could be the causes and possibly prevent suicide from happening but yet daily we hear stories of people taking their own lives leaving beloved families, friends, husbands, wives, children wondering.
In confronting the hard question, is it wrong to commit suicide? While on the hand is the ultimate sign of human weakness and failure. This article argues for civil rights for dying people. The creation of such rights should be understood as complementary to, but distinct from, existing initiatives to provide dying people with social benefits. A basis for rights for A basis for rights for terminally ill people can be found in the disability rights movement.
Through an ethnographic case study of two dying individuals, I argue that terminally ill people can be subjected to disability discrimination as it is understood within the dominant theoretical framework of disability rights: the social model of disability. Nevertheless, while disability rights provides a theoretical basis for understanding discrimination against people who are dying, existing U.
For this reason, it is necessary to develop a separate set of rights of the dying.
I conclude by arguing that such "dying rights" are a logical extension of disability rights, and will bring ancillary benefits to both disabled people and the disability rights movement itself. There is thus a strong foundation for a legal and political alliance between disability rights advocates and advocates for people who are dying. This article intervenes in the debate, among US disability rights advocates, about physician-assisted suicide PAS.
Absence of qualitative scrutiny of assessment process. No re-assessment or oversight when prescribed drugs are ingested. Recent pressures to extend Oregon's PAS law. Reasons given for seeking PAS indicate this is a societal rather than a clinical issue and raise the question whether adjudicating on requests for legalized PAS is an appropriate role for doctors.
Research into quality of decision-making in requests for PAS and into potential role of doctors as expert witnesses rather than judges in requests for PAS. These are the titles of laws in five US States which allow doctors to supply lethal drugs to seriously ill people who request them and who are thought to meet certain criteria so that they can use those drugs to take their own lives. In other words, these are laws legalizing physician-assisted suicide PAS.
In the UK there is no such law. PAS has also been legalized in the Netherlands and Canada , though as one component of wider-ranging laws permitting not only PAS but also physician-administered euthanasia PAE , in which a doctor administers rather than prescribes or supplies lethal drugs to a requesting patient. Switzerland is commonly, but mistakenly, thought to have legalized assisted suicide. Switzerland has an exception to its criminal code exempting such assistance from prosecution if it can be shown to have been given for non-self-serving reasons.
This exemption, which dates from , was not framed in the context of serious illness but was a civil libertarian measure. Nor does it embed assisted suicide within clinical practice. The criteria in these jurisdictions are broadly similar—an applicant must be terminally ill with a prognosis of 6 months or less of life remaining, acting voluntarily and without pressure, and mentally capable. The criteria for PAS in Canada and the Netherlands are less clearly defined and need to be seen within the context of the wider-ranging laws of which they are a part.
The specific focus of this article is on Oregon. References to the Act in footnotes use the formal ORS title, with the relevant section number shown. The DWDA permits doctors to prescribe lethal drugs to terminally ill patients who are considered to meet certain criteria.
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He or she must make an oral and a written request and reiterate the former no less than 15 days after making the initial oral request. The Act states ORS If the stated conditions are considered to be met, it falls to the attending doctor to prescribe lethal drugs and to report that he or she has done so. There have been 19 annual reports published by what is now the OHA covering the years — Figure 1 , which is taken from the report Published in February , shows the number of prescriptions for lethal drugs issued in each year and the number of deaths resulting from their ingestion.
It will be noted that the number of deaths in each year is less than the number of prescriptions issued. This is because some recipients around one in three over the lifetime of the DWDA do not take the drugs supplied to them but die from natural causes. It can be argued that supplying lethal drugs does not necessarily result in PAS but offers the prospect of an escape route if the patient feels his or her medical condition has become intolerable.
Others might argue that, given the sometimes considerable lapse of time between prescription and ingestion, the criteria on which the drugs were prescribed for example, having decision-making capacity or being free from pressure may no longer be fulfilled when they come to be taken. Another notable feature is the trend in numbers of deaths from PAS. Until the annual number of deaths from PAS was variable but generally upwards. This was followed by a sharp rise in and and a slight decline in —though, as the latest report makes clear, there remains a relatively large number cases where prescriptions for lethal drugs were issued in but, as at the January 23, cut-off point, the OHA had no information as to whether or not they had led to PAS.
Forty nine per cent were concerned about being a burden on their families, friends or caregivers. What do the data in the reports tell us about Oregon's experience of PAS? The reports are, as the statute requires, statistical analyses. They state how many people have died by PAS, what were their underlying medical conditions, how old they were and so on.
These data enable us to make some inferences about the operation of the law, but they do not tell us how requests for PAS are being handled—in particular, how thorough are the investigations made by the doctors who consider them and in what circumstances ingestion of prescribed lethal drugs takes place. A fundamental problem here is the absence of an independent qualitative audit system. A doctor who has prescribed lethal drugs is required to submit the relevant documentation to the OHA, but there is no body charged specifically with scrutinizing the quality of the assessment process.
Various research studies have been conducted since enactment of the DWDA to consider different aspects of the working of the law. Battin, MP et al , Journal of Medical Ethics ; — investigated the prevalence of PAS among various socio-economic groups, including the elderly, the poor, the less-well-educated, women and racial minorities.
The Right to Assisted Suicide
A riposte Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups — another perspective on Oregon's data, Finlay, I and George, R, Journal of Medical Ethics ; — in the same journal pointed out that this conclusion rested on a questionable methodology.
For example, the conclusion that the elderly were not at heightened risk had been reached by measuring the death rate from PAS among persons aged 85 or over with that of persons aged 18— Those aged 65—84, a group whom most would regard as elderly, had been excluded. Yet, as the official reports make clear, this latter group accounts for more than half of all deaths from PAS. The latest report gives the median age for PAS as 73 years. There were also conclusions which may perhaps have been valid in themselves but raised questions.
This may possibly be so, but it begs the question: are those with higher educational attainment at greater risk? More generally, it is arguable that the study relied too heavily on standard socio-economic groupings. While these may have relevance in addressing issues such as education, employment, housing or health, they are of doubtful value as measures of vulnerability where PAS is concerned.
This does not mean that only one in twenty applicants for PAS was so referred. The official reports are concerned only with those who have died by PAS in each year. They do not tell us how many people were referred to a specialist in capacity assessment and had their requests for PAS refused. However, the law is clear: if a doctor has doubts about an applicant's capacity, there must be a referral.
Is this happening in practice? Fifteen of the participants met the study's criteria for depression. Of the 42 participants who had died by the end of the study, 18 had received a prescription for lethal drugs under the DWDA. Three of them met the criteria for depression and had used the supplied drugs to end their lives. None of them had been evaluated by a mental health professional before their participation in the research. This finding cannot be taken as meaning that one in six of those who end their lives by PAS in Oregon are suffering from depressive disorder.
The sample was a small one and a more extensive study might perhaps produce different results. It does however raise concerns that applicants with depressive conditions may be getting through the net and ingesting lethal drugs without receiving the specialist psychological evaluation required by the Act. Oregon's law permits PAS for people who have been diagnosed as having a terminal illness. But this latter could occur years after diagnosis and after successive spells of decline and recovery, at one of the low points of which a doctor might possibly say that he or she would not be surprised if the patient died within the next 6 months, especially if the patient were frail and had other co-morbidities.
The difficulty lies in distinguishing the palliative phase of such illnesses, which may last for years, from the terminal stage, when death is inevitable and imminent. The reports shed no light on how this difficulty is being handled. Over the period — the median period of time between first request for PAS and death from ingestion of lethal drugs was 48 days 7 weeks.
However, this median was within a range of 14— days from 2 weeks to nearly 3 years.
In other words, while some recipients of lethal drugs have taken their lives on receiving them, others who have been prescribed such drugs on the strength of a 6-months-or-less prognosis have lived for up to 3 years before using them to take their own lives. How long these latter might have lived if they had not been prescribed lethal drugs is impossible to say. Not only does this situation underline the difficulties of accurate prognosis of terminal illness. It also raises the question whether those who postponed taking their lives for so long had had a serious and settled wish to die at the time of their application.
Oregon doctors may decline to consider requests for PAS. Two out of three of them do so Palliative Care and Ethics, Ed. As a result some, perhaps many, applicants for PAS have to seek out or be introduced to a minority of doctors who are willing to provide the service. Such doctors are unlikely to have any first-hand knowledge of the patient and must proceed largely on the basis of the case notes and what the patient chooses to reveal.
Knowing a patient well may not be so important a requirement for the normal purposes of clinical diagnosis and treatment. But the components of decision-making in PAS go beyond the clinical. They include consideration of such issues as how serious is a wish to die, what family or other dynamics might be at work in the background, what, if any, susceptibility exists to mood swings or depression and generally what makes the patient tick.
It is arguable that, if these decisions are to be knowledge-based, the attending doctor at least should have had primary responsibility for the applicant's care for a minimum period of time. Yet the reports tell us that the median length of the doctor—patient relationship for those who died by PAS since was just 13 weeks within a range of 0— weeks. This does not necessarily mean that these patients were being cared for in hospices.
Much of hospice care in Oregon is delivered via hospice-at-home programmes, in which patients are visited by doctors or nurses with some palliative care training.
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Moreover, to qualify for funded hospice care a person must be considered to have 6 months or less to live—the same criterion as for PAS. To enrol in a hospice programme a patient must also waive the right to curative or life-sustaining treatment. Most surveys seem to be agreed that palliative and hospice care has improved considerably in Oregon over the last 25 years. This raises the question: is there a connection here with enactment of the DWDA? Others, including Ganzini, have pointed out that palliative care has improved across all US States, as it has across many parts of the world.
The annual numbers of reported assisted deaths in Oregon do not appear high in isolation. However, it is necessary to remember that Oregon is a sparsely populated State. Its population of around 4 million is less than half that of London. Oregon's death rate from legalized assisted suicide is the equivalent of some PAS deaths in England and Wales annually if there were to be a similar law here.