Physician-assisted Suicide Research Articles

Affective Responses to Counter-Attitudinal Testimonials Drive Persuasive Effects: The Case of Physician-Assisted Suicide

Overtly persuasive narratives such as testimonials pose significant challenges for theories of narrative persuasion. Such theories argue that overt persuasive intent diminishes entertainment and entertaining narratives reduce counterarguing. We propose that testimonial narratives instead have persuasive advantages through their ability to arouse message-consistent emotions and reduce affective reactance to the messages. Participants ( n = 1478) were randomly assigned to read a testimonial narrative or a non-narrative article about physician-assisted suicide. Articles were perceived as highly persuasive and low in entertainment intent; the testimonial was higher than the non-narrative in perceived eudaimonic intent. As predicted, testimonials reduced counterarguing via increased meaningful affect and decreased affective reactance to the message. Interaction tests showed that these effects were stronger in counterattitudinal participants. Theoretical implications for understanding the effects of testimonial narratives, particularly when the narratives are eudaimonic, are discussed, as are innovations for measuring counterarguing and perceived message intent.

Suffering, Sanctity of Life and the Moral Dilemma of Physician-Assisted Suicide: What the Netherlands Teaches Us

Suffering, Sanctity of Life and the Moral Dilemma of Physician-Assisted Suicide: What the Netherlands Teaches Us

Long-term experience on assisted suicide in Switzerland: dementia, mental disorders, age-related polymorbidity and the slippery slope argument

ObjectivesAccording to the Swiss medico-ethical guidelines valid between 2004 and 2018, the key criterion for assisted suicide (AS) was that the patients who wished to die suffered with a disease leading to death in the foreseeable future. Critics of AS fears that broadening of the medical indications will lead to an uncontrolled expansion to persons who are not terminally ill (slippery slope argument). We evaluated to what extent this broadening took place in practice over time. Study designRetrospective national cohort study. MethodsBy using data of the Swiss Federal Statistical Office, we analyzed the long-term development of AS in Switzerland over a 20-year period (1999–2018; n = 8738 cases). We classified the cases into one of three categories regarding the aforementioned key criterion for AS. ResultsIn 43.6% of AS cases, the criterion ‘end of life is near’ was met. In 5.3% of cases, this criterion was not met (4.7%: mental disorders; 0.6%: dementia). In 51.1% of cases, the reason underlying AS comprised several, mostly age-related diseases and/or functional impairments; the aforementioned key criterion, however, was probably not met in most of the cases. Over time, the number of cases doubled over each 5-year period; this increase occurred similarly for the three categories. ConclusionThe fact that many AS cases took place outside the valid medico-ethical guidelines might be interpreted as a development in the idea of the slippery slope argument. The fact that the percentage distribution of these cases remained unchanged over time argues against it.

Who supports liberal policies? A tale of two referendums in Italy

We leverage a unique dataset at the municipality level in Italy to examine the factors that drive support for two separate referendum campaigns — one on the decriminalization of cannabis cultivation and the other on physician-assisted suicide. Using machine learning techniques, we identify key predictors of support for both referendums, including income, population density, and political leaning of the municipality. Our analysis also highlights that local economic conditions, such as the number of firms, and educational attainment, along with exposure to organized crime, are critical factors driving mobilization in favor of the cannabis referendum. In contrast, support for legalizing assisted suicide is more likely to be explained by religiosity.

Appraising publicly available online resources to support patients considering decisions about medical assistance in dying in Canada: an environmental scan.

Medical assistance in dying (MAiD) was legalized in Canada in 2016, with legislation updated in 2021. It is unclear whether resources are available to help patients make this difficult decision; therefore, we sought to identify and quality appraise Canadian MAiD resources for supporting patients making this decision. We conducted an environmental scan by searching Canadian websites for online MAiD resources that were published after the 2016 MAiD legislation, patient targeted, publicly accessible and able to inform decisions about MAiD in Canada. We excluded resources that targeted health care professionals or policy-makers, service protocols and personal narratives. Two authors appraised resources using the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Materials Assessment Tool (PEMAT) for health literacy. Descriptive analysis was conducted. We defined resources as patient decision aids if 7 IPDAS defining criteria were met, and we rated resources as adequate for understandability or actionability if the PEMAT score was 70% or greater. We identified 80 MAiD resources. As of March 2023, 62 resources (90%) provided eligibility according to the 2021 legislation and 11 did not discuss any eligibility criteria. The median IPDAS score was 3 out of 7; 52% discussed alternative options and none provided benefits or harms. Of 80 resources, 59% were adequate for understandability and 29% were adequate for actionability. Although many resources on MAiD were updated with 2021 legislation, few were adequate to support patients with lower health literacy. There is a need to determine whether a patient decision aid would be appropriate for people in Canada considering MAiD.

Clinical presentations of suicidality in relation to medical assistance in dying.

This study explores the assessments of mental health clinicians working with suicidal patients who requested access to medical assistance in dying (MAiD). A sample of convenience completed an online questionnaire about their experiences with suicidal patients. Respondents described their encounters with 227 suicidal patients: 44 requested access to MAiD, and 183 did not. Data were analyzed using chi-squared and simple t-test to identify differences between the respondents' descriptions of the two groups. Results noted differences between patients who experience suicide ideation and request MAiD (SPM), and those who experience suicide ideation and do not (SP). Overall, the SPM group was older, more physical health concerns, chronic pain, existential distress, and less hope. Many had experienced several episodes of mental health care and medication trials, though unlike the SP group, they had a split between accessing a little care and a lot of care. They also engaged in less suicide planning, and some had no history of suicide attempts. It is important that mental health clinicians learn to differentiate between MAiD requests due to an ongoing and irremediable mental disorder, and MAiD requests in response to circumscribed psychological suffering that could be relieved via a change in circumstances and/or access to different treatment options amenable to the patient.

Institutional Resistance to Medical Assistance in Dying in Canada: Arguments and Realities Emerging in the Public Domain.

Since the legalization of medical assistance in dying (MAiD) in Canada in 2016, volitional non-participation in MAiD on the part of some healthcare institutions has revealed ethical uncertainties, potential access problems, and policy gaps. The problem has remained much neglected in the literature base, with no comprehensive studies on the subject so far. We analyzed print media articles and grey literature on institutional objections to and non-participation in MAiD. Thematic analyses were performed on all data to better understand the diverse stakeholder arguments and positions that characterize this important public health debate. Our search yielded 89 relevant media articles and 22 legislative, policy, and other relevant documents published since 2016 in the English language. We identified four main themes about institutional refusals to participate in MAiD, articulated as the following questions: (1) Who has the right to conscience? (2) Can MAiD be considered a palliative practice? (3) Are there imbalances across diverse stakeholder rights and burdens? and (4) Where are the gaps being felt in MAiD service implementation? Stakeholder views about institutional conscience with respect to MAiD are varied, complex, and evolving. In the absence of substantial systematic evidence, public domain materials constitute a key resource for understanding the implications for service access and determining the relevance of this contentious issue for future MAiD research and policy.

One-way ticket to Zürich: presentations of ‘Suicide tourism’ in European news media

ABSTRACT In recent years, stories of individuals travelling to Switzerland for an assisted death have been the subject of a notable number of news reports, particularly in the UK, giving the impression that this is largely a British practice. Coverage of individuals undertaking this journey, colloquially known as ‘suicide tourists’, frequently features in newspaper media in other European countries however, presented as a rousing reminder of the incongruity between the modern desire for greater choice over one’s death, and the law on assisted suicide making this practice a crime in all but a few European nations. In this mixed-methods study I explore the framing of suicide tourism in the newspaper media of four Western European countries between 2002 and 2021. A quantitative analysis of trends in reporting was carried out initially, complemented by a qualitative thematic analysis of news stories using a critical discourse framework. Four themes indicative of a wider ‘European’ discourse employing common frames, language, and meaning were identified: 1/suicide tourism as an individual choice grounded on a desire for autonomy and self-determination 2/Dignitas as an ‘emergency exit’ 3/the law on assisted suicide as outdated and coercive, and 4/dying in Switzerland as a ‘good death’.

ICD-Based Cause of Death Statistics Fail to Provide Reliable Data for Medical Aid in Dying.

Objectives: To evaluate the most recent developments of medical aid in dying (MAID) in Switzerland and to test the reliability of reporting this phenomenon in cause of death statistics. Methods: By reviewing the MAID cases between 2018 and 2020, we compared the diseases and conditions underlying MAID reported by the ICD-based statistics provided by the Swiss Federal Statistical Office (FSO, n = 3,623) and those provided by the largest right-to-die organization EXIT (n = 2,680). Results: EXIT reported the motivations underlying the desire for death in a mixture of disease-specific and symptom-oriented categories; the latter including, for example, multimorbidity (26% of cases), and chronic pain (8%). Symptom-oriented categories were not included in the ICD-based FSO statistics. This led to the fact that the distribution of the diseases/conditions underlying MAID differed in 30%-40% of cases between both statistics. Conclusion: In order to reliably follow developments and trends in MAID, the diseases/conditions underlying the wish to die must be accurately recorded. Current methods of data collection using the ICD classification do not capture this information thoroughly ("MAID gap"). Newly created ICD codes for MAID must include both disease-specific and symptom-oriented categories.

PHYSICIAN-ASSISTED SUICIDE AS A CONSTITUTIONAL RIGHT: GLUCKSBERG REVISITED

“Glucksberg“ is celebrating its 25th anniversary. In 1997, the Supreme Court held that a right to (physician) assisted suicide was not protected by the Due Process Clause of the Fourteenth Amendment. However, the Court was wrong – back then and today. This is not only because of US case-law and US states legislation, but also because of international developments all pointing towards legalizing assisted suicide.

Medical assistance in dying law: a qualitative study of French cancer physicians

ObjectivesThe legal landscape surrounding end-of-life care in France is subject to frequent changes. A proposed law to legalise euthanasia in April 2021 has raised questions about the role of physicians....

Legalisation of euthanasia and assisted suicide: advanced cancer patient opinions – cross-sectional multicentre study

ObjectivesThe French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled...

Exploring How Internal Medicine Residents Approach Requests for Medical Assistance in Dying: An Exploratory Qualitative Study at the University of Calgary

To develop Medical Assistance in Dying (MAiD) competencies and curricula, we aimed to create a framework outlining how internal medicine (IM) residents approach MAiD requests and identify subsequent learning gaps. We used qualitative descriptive methodology to explore individual participant responses to three clinical vignettes centered on aspects of MAiD, followed by a group discussion. Responses were recorded and transcribed. Codes were reviewed and iteratively organized into themes, highlighting the steps taken for each MAiD scenario. Themes were compared and classified into broader categories within a framework to describe the participants’ overall approach to MAiD requests. Three overarching categories illustrated the approach taken by participants when faced with MAiD requests: 1) Action: the pragmatic steps participants took to respond to requests 2) Decision: the rationale behind how participants decided if MAiD was an option; and 3) Reaction: the emotional reactions that arise from requests; each highlighted significant learning gaps. Participants lacked understanding in concurrent medical and symptom management, MAiD eligibility and referral criteria, roles and responsibilities, and were uncomfortable discussing MAiD. IM residents not only require education on MAiD as a topic but on developing an approach to responding to requests and ways of addressing subsequent personal reactions.

Conventional and assisted suicide in Switzerland: Insights into a divergent development based on cancer-associated self-initiated deaths.

We tested the hypothesis of supporters of assisted dying that assisted suicide (AS) might be able to prevent cases of conventional suicide (CS). By using data from the Federal Statistical Office, we analyzed the long-term development of 30,756 self-initiated deaths in Switzerland over a 20-year period (1999-2018; CS: n = 22,018, AS: n = 8738), focusing on people suffering from cancer who died from AS or CS. While cancer was the most often listed principal disease for AS (n = 3580, 41.0% of AS cases), cancer was listed in only a small minority of CS cases (n = 832, 3.8% of CS cases). There was a significant increase in the absolute number of cancer-associated AS cases: comparing four 5-year periods, there was approximately a doubling of cases every 5 years (1999-2003: n = 228 vs.2004-2008: n = 474, +108% compared with the previous period; 2009-2013: n = 920, +94%; 2014-2018: n = 1958, +113%). The ratio of cancer-associated AS in relationship with all cancer-associated deaths increased over time to 2.3% in the last observation period (2014-2018). In parallel, the numbers of cancer-associated CS showed a downward trend only at the beginning of the observation period (1999-2003, n = 240 vs. 2004-2008, n = 199, -17%). Thereafter, the number of cases remained stable in the subsequent 5-year period (2009-2013, n = 187, -6%), and increased again toward the most recent period (2014-2018, n = 206, +10%). The assumption that, with the increasingly accessible option of AS for patients with cancer, CS suicide will become "superfluous" cannot be confirmed. There are strong reasons indicating that situations and circumstances of cancer-associated CS are different from those for cancer-associated AS.

Journey to Switzerland as a state of exception: a ‘homo sacer’ Italian experience

ABSTRACT In Italy, the topic of assisted suicide (AS) has been gaining increasing interest in recent years through a number of ‘travel to Switzerland’ cases. Italy, together with other European countries where this practice is not legalised, is involved in the ‘Swiss effect’, that is, ‘suicide tourism’ of ill people. This article looks at the experience of a patient who went to Switzerland for AS (‘Andrea’), accompanied by a photojournalist (‘Giordano’) who discovered that he/she was a healthy person. Giordano was interviewed following the methodology of the interpretative phenomenological analysis, and his answers underwent qualitative analyses that highlighted four main themes illustrating how the experience was deeply traumatic: Giordano’s reasons for addressing AS and his accompanying Andrea; The family shock; Human free will and God’s willingness; Giordano’s emotions and representation of death. On the basis of these results, some biopolitical aspects are discussed in the space of ‘homo sacer’, ‘state of exception’ and ‘social immunisation’. Particular attention is given to the issue of suicide prevention and to its total medicalisation through the palliative care approach.

Medical assistance in dying in Canada: A scoping review on the concept of suffering.

Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N=1027) were identified from a review of 6 databases and GL documents (N=537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.

Medical Information During Trauma Resuscitations: Are Smartphones the Contemporary Medical ID Bracelet?

IntroductionSmartphone emergency medical identification (SEMID) applications are built-in health information-storing functions that are accessible without a passcode. The utility of these applications in the real-time resuscitation of trauma patients is unknown. MethodsWe prospectively evaluated all trauma activation patients ≥16 y and unable to provide a medical history for any reason for the presence of a smartphone at our urban level I center between October 2020 and September 2021. Available smartphones were queried for SEMID utilization, categories of information contained, and real-time clinical relevance. ResultsOne hundred and forty three patients with a median age of 39 y [interquartile range 28-59] and Injury Severity Score of 16 [2-29] were included. 30 (21%) patients arrived with a smartphone, 27 (90%) of which were accessible. 8 (30%) of those individuals utilized a SEMID application, and SEMID information was relevant for patient care in 6 cases (75%). The extracted information included: identifiers (75%), emergency contacts (50%), height/weight (38%), allergies (38%), age (38%), medications (25%), medical history (13%), and blood type (13%). ConclusionsApproximately one in five altered trauma patients have smartphones present at arrival, some of which contain medical information pertinent for immediate care. There is a pressing need for education and our institution has developed a publicly-facing campaign with shareable materials to improve SEMID awareness and utilization. Other centers are likely to find similar benefit.

Health care providers’ early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service

BackgroundIn November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.AimTo explore the early experiences of health care providers (HCPs) who do and do not provide AD services seven months after legalisation of AD to provide the first empirical account of how the AD service is operating in New Zealand’s distinctive healthcare environment and cultural context.DesignQualitative exploratory design using semi-structured individual and focus group interviewing with a range of HCPs.ResultsTwenty-six HCPs participated in the study. Through a process of thematic analysis four key themes were identified: (1) Difference in organisational response to AD; (2) challenges in applying the law; (3) experiences at the coal face; and (4) functionality of the AD system.ConclusionA range of barriers and enablers to successful implementation of AD were described. Adoption of open and transparent organisational policies, ongoing education of the workforce, and measures to reduce stigma associated with AD are necessary to facilitate high quality AD service provision. Future research into the factors that influence responses to, and experience of AD; the impact of institutional objection; and the extent to which HCP perspectives evolve over time would be beneficial. In addition, further research into the integration of AD within Māori health organisations is required.

Brain–Computer Interfaces, Completely Locked-In State in Neurodegenerative Diseases, and End-of-Life Decisions

In the future, policies surrounding end-of-life decisions will be faced with the question of whether competent people in a completely locked-in state should be enabled to make end-of-life decisions via brain-computer interfaces (BCI). This article raises ethical issues with acting through BCIs in the context of these decisions, specifically self-administration requirements within assisted suicide policies. We argue that enabling patients to end their life even once they have entered completely locked-in state might, paradoxically, prolong and uphold their quality of life.

Institutional Objection to Voluntary Assisted Dying in Victoria, Australia: An Analysis of Publicly Available Policies

BackgroundVictoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to considerObjectiveTo describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria.MethodsPolicies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically analysed using the framework method.ResultsThe study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice.ConclusionThis study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions’ public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions.