Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label End of Life Issues. Show all posts
Showing posts with label End of Life Issues. Show all posts

Wednesday, April 24, 2024

What Deathbed Visions Teach Us About Living

Phoebe Zerwick
The New York Times
Originally posted March 12, 2024

Here is an excerpt:

At the time, only a handful of published medical studies had documented deathbed visions, and they largely relied on secondhand reports from doctors and other caregivers rather than accounts from patients themselves. On a flight home from a conference, Kerr outlined a study of his own, and in 2010, a research fellow, Anne Banas, signed on to conduct it with him. Like Kerr, Banas had a family member who, before his death, experienced visions — a grandfather who imagined himself in a train station with his brothers.

The study wasn’t designed to answer how these visions differ neurologically from hallucinations or delusions. Rather, Kerr saw his role as chronicler of his patients’ experiences. Borrowing from social-science research methods, Kerr, Banas and their colleagues based their study on daily interviews with patients in the 22-bed inpatient unit at the Hospice campus in the hope of capturing the frequency and varied subject matter of their visions. Patients were screened to ensure that they were lucid and not in a confused or delirious state. The research, published in 2014 in The Journal of Palliative Medicine, found that visions are far more common and frequent than other researchers had found, with an astonishing 88 percent of patients reporting at least one vision. (Later studies in Japan, India, Sweden and Australia confirm that visions are common. The percentages range from about 20 to 80 percent, though a majority of these studies rely on interviews with caregivers and not patients.)

In the last 10 years, Kerr has hired a permanent research team who expanded the studies to include interviews with patients receiving hospice care at home and with their families, deepening the researchers’ understanding of the variety and profundity of these visions. They can occur while patients are asleep or fully conscious. Dead family members figure most prominently, and by contrast, visions involving religious themes are exceedingly rare. Patients often relive seminal moments from their lives, including joyful experiences of falling in love and painful ones of rejection. Some dream of the unresolved tasks of daily life, like paying bills or raising children. Visions also entail past or imagined journeys — whether long car trips or short walks to school. Regardless of the subject matter, the visions, patients say, feel real and entirely unique compared with anything else they’ve ever experienced. They can begin days, even weeks, before death. Most significant, as people near the end of their lives, the frequency of visions increases, further centering on deceased people or pets. It is these final visions that provide patients, and their loved ones, with profound meaning and solace.

Here is a summary:

The article explores the phenomenon of deathbed visions experienced by dying individuals. These visions involve seeing and communicating with angels and departed loved ones, instilling a sense of peace and anticipation for the afterlife. The experiences are described as distinct from hallucinations and are often witnessed by family members and medical staff present during the individual's passing. The article emphasizes how these visions can transform perceptions of death, inspiring awe and encouraging a focus on love and spiritual well-being in daily life.

Tuesday, March 28, 2023

Medical assistance in dying (MAiD): Ethical considerations for psychologists

Koocher, G. P., Benjamin, G. A. H.,  et al. (2023). 
Professional Psychology: 
Research and Practice, 54(1), 2–13.


Significant ethical challenges arise when mental health practitioners care for patients who seek to accelerate their own dying for rational medically valid reasons. Current and proposed laws provide for medical assistance in dying (MAiD) in several U.S. jurisdictions, all of Canada, and several other nations. Differing provisions of these laws complicate their utility for some patients who seek aid in dying. Some extant laws include roles that mental health professionals might play in assessing patients’ competence or capacity to consent, mental illness, or other cognitive and behavioral factors. Practitioners who choose to accept roles in the MAiD process must consider and resolve a number of ethical challenges including potential conflicts between and among laws, ethical standards, third-party requests, personal values, and patients’ wishes. These include becoming aware of patients who may wish to act independently to end their lives when MAiD laws might otherwise exclude them. Examples from actual cases and the resultant discussion will form a basis for exploration of the ethical and legal complexities confronted when psychologists become engaged in the process either intentionally or incidentally. The lead article (Koocher) is not intended to comprehensively address MAiD in all of its complexity but rather to trigger a thoughtful discussion among the accompanying commentaries.

Impact Statement

Public Significance Statement—Current and proposed laws provide for medical assistance in dying (MAiD), sometimes described as physician-assisted suicide, in several U.S. jurisdictions, all of Canada, and in several other nations. Some such laws require psychological input, usually from either a psychologist or a psychiatrist. The limited scope of existing laws may result in some patients suffering with debilitating, painful, chronic, and fatal illnesses to consider suicide without medical assistance. With or without MAiD legislation, mental health professionals will come in contact with such patients and must consider the potentially complex ethical ramifications of caring for such patients. 


The culture of dying in America too often involves end-of-life care provided by strangers in institutional settings. Government and professional regulators often assume a parentalistic stance that effectively diminishes personal control of the dying process. Legalized MAiD offers an important option to those suffer from an irremediable medical condition and desire access to medical procedures to hasten death in a peaceful and dignified manner. Patients confronting chronic terminal illness have legitimate interests in controlling their own dying with quality care and support. Perhaps the most valuable and meaningful aspect of dying would include the presence of a community of care that demonstrates to the dying person that they will not feel abandoned (Campbell, 2019). Psychologists can play a significant role in making this happen. Ethical, professional, and legal controversies will abound as MAiD becomes more socially prevalent, and it will.

Wednesday, December 28, 2022

Physician-assisted suicide is not protected by Massachusetts Constitution, top state court rules

Chris Van Buskirk
Originally posted 6 Dec 22

The state’s highest court ruled Monday morning that the Massachusetts state constitution does not protect physician-assisted suicide and that laws around manslaughter may prohibit the practice.

The decision affects whether doctors can prescribe lethal amounts of medication to terminally ill patients that would end their life. The plaintiffs, a doctor looking to provide physician-assisted suicide and a patient with an incurable cancer, argued that patients with six months or less to live have a constitutional right to bring about their death on their own terms.

But defendants in the case have said that the decision to legalize or formalize the procedure here in Massachusetts is a question best left to state lawmakers, not the courts. And in an 89-page ruling, Associate Justice Frank Gaziano wrote that the Supreme Judicial Court agreed with that position.

The court, he wrote, recognized the “paramount importance and profound significance of all end-of-life decisions” but that the Massachusetts Declaration of Rights does not reach so far as to protect physician-assisted suicide.

“Our decision today does not diminish the critical nature of these interests, but rather recognizes the limits of our Constitution, and the proper role of the judiciary in a functioning democracy. The desirability and practicality of physician-assisted suicide raises not only weighty philosophical questions about the nature of life and death, but also difficult technical questions about the regulation of the medical field,” Gaziano wrote. “These questions are best left to the democratic process, where their resolution can be informed by robust public debate and thoughtful research by experts in the field.”

Plaintiff Roger Kligler, a retired physician, was diagnosed with stage four metastatic prostate cancer, and in May 2018, a doctor told him that there was a fifty percent chance that he would die within five years.

Kligler, Gaziano wrote in the ruling, had not yet received a six-month prognosis, and his cancer “currently has been contained, and his physician asserts that it would not be surprising if Kligler were alive ten years from now.”

Tuesday, February 15, 2022

How do people use ‘killing’, ‘letting die’ and related bioethical concepts? Contrasting descriptive and normative hypotheses

Rodríguez-Arias, D., et al., (2009)
Bioethics 34(5)


Bioethicists involved in end-of-life debates routinely distinguish between ‘killing’ and ‘letting die’. Meanwhile, previous work in cognitive science has revealed that when people characterize behaviour as either actively ‘doing’ or passively ‘allowing’, they do so not purely on descriptive grounds, but also as a function of the behaviour’s perceived morality. In the present report, we extend this line of research by examining how medical students and professionals (N = 184) and laypeople (N = 122) describe physicians’ behaviour in end-of-life scenarios. We show that the distinction between ‘ending’ a patient’s life and ‘allowing’ it to end arises from morally motivated causal selection. That is, when a patient wishes to die, her illness is treated as the cause of death and the doctor is seen as merely allowing her life to end. In contrast, when a patient does not wish to die, the doctor’s behaviour is treated as the cause of death and, consequently, the doctor is described as ending the patient’s life. This effect emerged regardless of whether the doctor’s behaviour was omissive (as in withholding treatment) or commissive (as in applying a lethal injection). In other words, patient consent shapes causal selection in end-of-life situations, and in turn determines whether physicians are seen as ‘killing’ patients, or merely as ‘enabling’ their death.

From the Discussion

Across three  cases of  end-of-life  intervention, we find  convergent evidence  that moral  appraisals shape behavior description (Cushman et al., 2008) and causal selection (Alicke, 1992; Kominsky et al., 2015). Consistent  with  the  deontic  hypothesis,  physicians  who  behaved  according  to  patients’  wishes  were described as allowing the patient’s life to end. In contrast, physicians who disregarded the patient’s wishes were  described  as  ending the  patient’s  life.  Additionally,  patient  consent  appeared  to  inform  causal selection: The doctor was seen as the cause of death when disregarding the patient’s will; but the illness was seen as the cause of death when the doctor had obeyed the patient’s will.

Whether the physician’s behavior was omissive or commissive did not play a comparable role in behavior description or causal  selection. First, these  effects were weaker  than those of patient consent. Second,  while the  effects  of  consent  generalized to  medical  students  and  professionals,  the  effects of commission arose only among lay respondents. In other words, medical students and professionals treated patient consent as the sole basis for the doing/allowing distinction.  

Taken together, these  results confirm that  doing and  allowing serve a  fundamentally evaluative purpose (in  line with  the deontic  hypothesis,  and Cushman  et al.,  2008),  and only  secondarily serve  a descriptive purpose, if at all. 

Thursday, August 22, 2019

New Jersey will allow terminally ill patients to end their lives

Taylor Romine
Originally posted July 1, 2019

Terminally ill adults in New Jersey will now be able to ask for medical help to end their lives.

In April, Gov. Phil Murphy signed the Medical Aid in Dying for the Terminally Ill Act. It goes into effect Thursday.

It allows adults with a prognosis of six months or less to live to get a prescription for life-ending medication.

Other jurisdictions that allow physician-assisted suicide are: California, Colorado, Oregon, Vermont, Washington, Hawaii, Montana and the District of Columbia.

The law requires either a psychiatrist or psychologist determine that the patient has the mental capacity to make the decision. The prescription is a series of self-administered pills that can be taken at home.

"Allowing residents with terminal illnesses to make end-of-life choices for themselves is the right thing to do," Murphy said in a statement.

The info is here.

Monday, September 17, 2018

How our lives end must no longer be a taboo subject

Kathryn Mannix
The Guardian
Originally published August 16, 2018

Here is an excerpt:

As we age and develop long-term health conditions, our chances of becoming suddenly ill rise; prospects for successful resuscitation fall; our youthful assumptions about length of life may be challenged; and our quality of life becomes increasingly more important to us than its length. The number of people over the age of 85 will double in the next 25 years, and dementia is already the biggest cause of death in this age group. What discussions do we need to have, and to repeat at sensible intervals, to ensure that our values and preferences are understood by the people who may be asked about them?

Our families need to know our answers to such questions as: how much treatment is too much or not enough? Do we see artificial hydration and nutrition as “treatment” or as basic care? Is life at any cost or quality of life more important to us? And what gives us quality of life? A 30-year-old attorney may not understand that being able to hear birdsong, or enjoy ice-cream, or follow the racing results, is more important to a family’s 85-year-old relative than being able to walk or shop. When we are approaching death, what important things should our carers know about us?

The info is here.

Thursday, July 26, 2018

Number of Canadians choosing medically assisted death jumps 30%

Kathleen Harris
Originally posted June 21, 2018

There were 1,523 medically assisted deaths in Canada in the last six-month reporting period — a nearly 30 per cent increase over the previous six months.

Cancer was the most common underlying medical condition in reported assisted death cases, cited in about 65 per cent of all medically assisted deaths, according to the report from Health Canada.

Using data from Statistics Canada, the report shows medically assisted deaths accounted for 1.07 per cent of all deaths in the country over those six months. That is consistent with reports from other countries that have assisted death regimes, where the figure ranges from 0.3 to four per cent.

The information is here.

Monday, May 28, 2018

This Suicide Pod Dubbed 'the Tesla of Death' Lets You Kill Yourself Peacefully

Loukia Papadopoulos
Interesting Engineering
Originally posted April 27, 2018

A new controversial pod for ending one’s life is on the market and it is being dubbed the Tesla of death and its founder, the Elon Musk of suicide. The pod, developed by euthanasia campaigner Dr. Philip Nitschke, is called the Sarco and it seeks to revolutionize the way we die.

The Sarco's website features a thought-provoking question on its landing page. “What if we had more than mere dignity to look forward to on our last day on this planet?” reads the site.

A description of the pod goes on to explain that “the elegant design was intended to suggest a sense of occasion: of travel to a ‘new destination’, and to dispel the ‘yuk’ factor.” If this sounds like a macabre joke, rest assured it is not.

The article is here.

Monday, December 18, 2017

Unconscious Patient With 'Do Not Resuscitate' Tattoo Causes Ethical Conundrum at Hospital

George Dvorsky
Originally published November 30, 2017

When an unresponsive patient arrived at a Florida hospital ER, the medical staff was taken aback upon discovering the words “DO NOT RESUSCITATE” tattooed onto the man’s chest—with the word “NOT” underlined and with his signature beneath it. Confused and alarmed, the medical staff chose to ignore the apparent DNR request—but not without alerting the hospital’s ethics team, who had a different take on the matter.

But with the “DO NOT RESUSCITATE” tattoo glaring back at them, the ICU team was suddenly confronted with a serious dilemma. The patient arrived at the hospital without ID, the medical staff was unable to contact next of kin, and efforts to revive or communicate with the patient were futile. The medical staff had no way of knowing if the tattoo was representative of the man’s true end-of-life wishes, so they decided to play it safe and ignore it.

The article is here.

Friday, May 12, 2017

Physicians, Not Conscripts — Conscientious Objection in Health Care

Ronit Y. Stahl and Ezekiel J. Emanuel
N Engl J Med 2017; 376:1380-1385

“Conscience clause” legislation has proliferated in recent years, extending the legal rights of health care professionals to cite their personal religious or moral beliefs as a reason to opt out of performing specific procedures or caring for particular patients. Physicians can refuse to perform abortions or in vitro fertilization. Nurses can refuse to aid in end-of-life care. Pharmacists can refuse to fill prescriptions for contraception. More recently, state legislation has enabled counselors and therapists to refuse to treat lesbian, gay, bisexual, and transgender (LGBT) patients, and in December, a federal judge issued a nationwide injunction against Section 1557 of the Affordable Care Act, which forbids discrimination on the basis of gender identity or termination of a pregnancy.

The article is here, and you need a subscription.

Here is an excerpt:

Objection to providing patients interventions that are at the core of medical practice – interventions that the profession deems to be effective, ethical, and standard treatments – is unjustifiable (AMA Code of Medical Ethics [Opinion 11.2.2]10).

Making the patient paramount means offering and providing accepted medical interventions in accordance with patients’ reasoned decisions. Thus, a health care professional cannot deny patients access to medications for mental health conditions, sexual dysfunction, or contraception on the basis of their conscience, since these drugs are professionally accepted as appropriate medical interventions.

Monday, February 27, 2017

King Introduces End-of-Life Counseling Bill

Jan 11, 2017
Press Release

Congressman Steve King released the following statement after re-introducing the End-of-Life Counseling Bill:

“A year ago this month, the government increased control over one of the most highly personal healthcare decisions an individual can make when the Centers for Medicare and Medicaid Services (CMS) began paying doctors to counsel patients about end-of-life care,” said King. “Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years in exchange for their compelled funding of the program during their working years.

Furthermore, this exact provision was removed from the final draft of Obamacare in 2009 as a direct result of public outcry. The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life. My legislation prohibits Medicare payments for end-of-life counseling, blocking this harmful regulation before our government imposes yet another life-devaluing policy on the American people. ”

The bill is here.

"Just because you do not take an interest in politics doesn't mean politics won't take an interest in you." -Pericles

Sunday, November 13, 2016

The VSED Exit: A Way to Speed Up Dying, Without Asking Permission

by Paula Span
The New York Times
Originally published October 21, 2016

Here is an excerpt:

In end-of-life circles, this option is called VSED (usually pronounced VEEsed), for voluntarily stopping eating and drinking. It causes death by dehydration, usually within seven to 14 days. To people with serious illnesses who want to hasten their deaths, a small but determined group, VSED can sound like a reasonable exit strategy.

Unlike aid with dying, now legal in five states, it doesn't require governmental action or physicians' authorization. Patients don't need a terminal diagnosis, and they don't have to prove mental capacity. They do need resolve.

"It's for strong-willed, independent people with very supportive families," said Dr. Timothy Quill, a veteran palliative care physician at the University of Rochester Medical Center.

He was speaking at a conference on VSED, billed as the nation's first, at Seattle University School of Law this month. It drew about 220 participants -- physicians and nurses, lawyers, bioethicists, academics of various stripes, theologians, hospice staff. (Disclosure: I was also a speaker, and received an honorarium and some travel costs.)

What the gathering made clear was that much about VSED remains unclear.

Is it legal?

For a mentally competent patient, able to grasp and communicate decisions, probably so, said Thaddeus Pope, director of the Health Law Institute at Mitchell Hamline School of Law in St. Paul, Minn. His research has found no laws expressly prohibiting competent people from VSED, and the right to refuse medical and health care intervention is well established.

The article is here.

Monday, October 24, 2016

Should doctors have the legal right to refuse care?

By Lisa Rapaport
Reuters Health
Originally published October 5, 2016

Physicians shouldn’t have the legal right to act as conscientious objectors and refuse to provide services like abortion or assisted suicide even when these things conflict with their personal values, some doctors argue.

That’s because access to care should take priority, and conscientious objectors may make it more difficult for patients to get treatment they need, Dr. Julian Savulescu of the University of Oxford in the U.K. and Udo Schuklenk of Queens University in Ontario, Canada, argue in an article in the journal Bioethics.

They make their case as a growing number of countries worldwide are grappling with how much autonomy to give patients and doctors to make decisions about care at the very beginning and end of life, particularly in an era when new technology and social media keep pushing the boundaries of long-held personal and religious beliefs.

The article is here.

Thursday, April 28, 2016

Canadian Prime Minister Seeks to Legalize Physician-Assisted Suicide

By Ian Austen
The New York Times
Originally posted April 14, 2016

The government of Prime Minister Justin Trudeau introduced legislation on Thursday to legalize physician-assisted suicide for Canadians with serious medical conditions.

The proposed law limits physician-assisted suicides to Canadians and residents, who are eligible to participate in the national health care system, preventing a surge in medical tourism among the dying from other countries. Assisted suicide is legal in only a few American states, including Oregon and Vermont.

Under Canada’s proposed law, people who want to die will be able to either commit suicide with medication provided by their doctors or have the doctors administer the dose. Family members will be allowed to assist patients with their death.

The article is here.

Wednesday, February 10, 2016

End-of-life care in U.S. not as costly as in Canada

By Jessica McDonald
Originally posted January 10, 2016

The United States has a reputation for providing costly -- and often unwanted -- end-of-life care. But the first study to do an international comparison finds it's not as egregious as we thought.

Compared with patients in other developed nations, Americans diagnosed with cancer spend more time in the intensive care unit and get more chemotherapy in the last months of their lives.

But fewer patients are in the hospital when they die. And the overall bill, while high, isn't the steepest. That honor goes to Canada.

"We found that end-of-life care in the United States is not the worst in the world, and I think that surprises a lot of people," said Dr. Ezekiel Emanuel, a medical ethicist at the University of Pennsylvania.

The article is here.

Sunday, January 24, 2016

Opponents fail to derail the state's right-to-die measure, but they may yet try again in court

By The Times Editorial Board
The Los Angeles Times
Originally posted January 7, 2016

Here is an excerpt:

The group behind the referendum attempt, known as Seniors Against Suicide, says it is now contemplating a lawsuit to stop the law's implementation. The law is set to go into effect 90 days after the state Legislature concludes the still-open special session on healthcare.

We respect the law's opponents, including the Roman Catholic Church and some disability-rights advocates; they waged a passionate battle — both moral and practical — against it. But we don't share their fears. There is no evidence that a law this narrow would lead uncaring health insurers or family members to coerce sick patients to kill themselves in order to save on medical costs.

To the contrary, two decades of experience with Oregon's landmark Death with Dignity Act suggests that it will be used sparingly. In the first 17 years, just 1,327 people in Oregon requested a life-ending prescription from a doctor. More than a third of them then chose not to use the prescription.

The article is here.

Thursday, January 14, 2016

Blue Cross expands benefits for end-of-life care

By Priyanka Dayal McCluskey
The Boston Globe
First posted on December 28, 2015

Here is an excerpt:

And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives.

“The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues [around death and dying], but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.”

The article is here.

Monday, November 30, 2015

Lessons in End-of-Life Care From the V.A.

By David Casarett
The New York Times
November 11, 2015

Here are two excerpts:

Sheila had just received a “patient experience” survey that asked for her opinions about her recent stay in one of our hospitals. He read off some of the questions, in a voice that was tinged with a mix of anger and amusement. Those questions were about the quality of the food (“unimpressive”), the availability of parking (“O.K.”), and the cleanliness of the rooms (“perfect”).

But, he said, “You didn’t ask us about what really matters.”

What he meant, he explained, was that these questions didn’t reflect what was important to a 73-year-old woman with incurable breast cancer who knows she’s going to die in the next six months. And they didn’t assess how well we were supporting her husband, who was overwhelmed with being a caregiver and advocate, a father and grandfather. We asked for their opinions, but we didn’t ask the right questions.


We need to be asking these questions. National surveys could easily be modified to include questions that are important to patients like Sheila. We could include questions about emotional and spiritual support, control over decisions, adequacy of information and respect for dignity. Those sorts of questions are arguably important for all of us, but they’re particularly relevant to those who are facing advanced, incurable illnesses.

The entire article is here.

Friday, October 16, 2015

UK end-of-life care 'best in world'

By Nick Triggle
BBC News
Originally posted October 6, 2015

End-of-life care in the UK has been ranked as the best in the world with a study praising the quality and availability of services.

The study of 80 countries said thanks to the NHS and hospice movement the care provided was "second to none".

Rich nations tended to perform the best - with Australia and New Zealand ranked second and third respectively.

But the report by the Economist Intelligence Unit praised progress made in some of the poorest countries.

The article and the rankings are here.

Friday, September 11, 2015

Safeguarding choice at the end of life

By Dominic Wilkinson
J Med Ethics 2015;41:575-576

Across the world, in countries with permissive or restrictive existing legislation, debates about Euthanasia and Assisted Suicide (EAS) continue to grip politicians, ethicists, physicians and the wider public.

Early debates about EAS focused on whether it could ever be ethical for a physician to actively cause the death of a patient. However, most contemporary writers, including most of the contributors to this special double issue of the JME appear to accept that such actions could, in some circumstances, be ethical. Current debate is mostly focused instead on which actions are permissible, when they are permissible, and what safeguards are necessary to protect the vulnerable.

There are two separate justifications for EAS. The first of these is based on the autonomy of competent patients, on their right to make important decisions about their own lives. Arguably, a decision about continuing or not continuing your life in the face of severe suffering is the most important decision that you could make. Correspondingly, we have strong autonomy based reasons for permitting that choice. (While some Kantians might claim that a decision to die, and thereby to end one's autonomous agency could not be compatible with autonomy and dignity, Michael Cholbi points out (see page 607) that a sophisticated Kantian position on EAS is neither completely restrictive nor permissive). The second justification for EAS is based on the interests of a patient, and a concern that continued life for some individuals may be so extraordinarily and intensely unpleasant that it would be better for them to die.

The entire article is here.