bs_bs_banner
Bioethics ISSN 0269-9702 (print); 1467-8519 (online)
Volume 31 Number 6 2017 pp 422–423
EDITORIAL
NEW FRONTIERS IN END-OF-LIFE ETHICS
(AND POLICY): SCOPE, ADVANCE
DIRECTIVES AND CONSCIENTIOUS
OBJECTION
Readers opposed to medically assisted suicide and medi-
cally assisted dying will probably disagree with this
assessment, but let me begin this Editorial by saying that
the arguments against medically assisted suicide and vol-
untary euthanasia have lost their case, not only in peer
reviewed journals but also as far as public opinion, in
most liberal Western democracies, is concerned.
More jurisdictions will introduce these end-of-life
options, because evidence from jurisdictions that have
decriminalized shows that there has been no slippery
slope to abusive practices, and because the much-
maligned respect for citizens autonomous choices turns
out to be something to which we do actually ascribe high
importance in liberal polities. Skirmishing activities
involving vague terminology such as human dignity or
vulnerability as justifications for the continuing criminal-
ization of assisted dying have not been terribly successful.
However, it would be premature to conclude that all
arguments are settled now, if not in politics and law, and
that, certainly in ethics, nothing much original could be
added to the existing corpus of critical analysis and argu-
ment. In fact jurisdictions considering the decriminaliza-
tion of medical aid in dying are grappling today with
three issues that deserve further analysis.
Scope
If respect for patient choice is a primary motive for pro-
viding people with assistance in dying, scope of eligibility
is bound to become the next point of conflict between
those favouring permissive regimes and those favouring
restrictive regimes. Those favouring restrictive regimes
consist of the old guard of opponents to any kind of
medical aid in dying, as well as those who think medical
aid in dying should only be provided to people who are
reasonably close to their illness-related death. The ethical
issues related to eligibility are complicated, as some auton-
omous patients suffering from, for instance, treatment-
resistant depression demand access to medical aid in
dying. Empirical questions arise, not only about their
decision-making capacity, but also about the possibility
that successful treatments might become available during
their natural life-span. Who should have the final word?
My views on this question are no secret. If patients with
decision-making capacity who have undergone available
treatment options, for a particular condition that renders
their lives not worth living to them, request medical aid in
doi:10.1111/bioe.12372
dying, it would be callous to disregard such a request.
Proponents of restrictive regimes deploy arguments famil-
iar to readers who know the history of debates on medical
aid in dying. They question our ability to determine
capacity (in all, many or some cases). They also tend to
insist that better mental health-care resources would elimi-
nate all, or most, requests for medical aid in dying from
such people. There is not a great deal of literature on the
issue of scope at the time of writing.
Advance Directives
Advance Directives are seen as a panacea to proponents
of a permissive regime for situations where a formerly
competent patient has permanently lost decision-
making capacity. There is some plausibility to the idea
that we can extend our autonomous decision-making to
situations where we no longer have the capacity to
make end-of-life choices. In rapidly ageing Western
societies with large number of patients likely to develop
dementia in old age, this could be a solution, or so it is
argued. The problem is that Advance Directives, by def-
inition, would only be triggered when a patient has lost
psychological continuity. It is far from clear why in the
absence of the person who made that Advance Direc-
tive it should still apply to that persons body. It is con-
ceivable that a competent patient draws up an Advance
Directive that would trigger medical aid in dying when
they have lost all competence. That then incompetent
patient might not actually find their life not worth liv-
ing, yet the Advance Directive would demand that their
life be terminated. Another issue is that it is, for all
practical intents and purposes, difficult to draw up a
casuistry sufficiently detailed to cover particular situa-
tions in which patients might find themselves. It seems
that an alternative to simple Advance Directives could
be to make decisions with regard to the ending of life
under such circumstances subject to a determination
that the quality of such patients lives renders it not
worth living any longer, either in addition to an
Advance Directive, or, indeed, in lieu of an Advance
Directive. The last word on Advance Directives has not
been spoken, so let me encourage you to consider focus-
ing your attention on this issue.
CONSCIENTIOUS
Objection
Last but not least, a final issue that has received a fair
amount of attention recently, as far as the peer reviewed
literature is concerned, is that of the accommodation of
C 2017 John Wiley & Sons Ltd
V
 Editorial
conscientious objectors among health-care professionals.
At the heart of the conflict is whether health-care profes-
sionals who object on conscience grounds to the provi-
sion of particular medical services to eligible patients
who request those services, should be accommodated by
our health-care systems. That they ought to be accom-
modated has traditionally been taken as the gospel in
most countries. The same holds true for the many hospi-
tals which are, while not financed by, often managed by
religious organizations. During the last decade or so, a
C 2017 John Wiley & Sons Ltd
V
423
number of leading voices in bioethics have questioned
the rationale underlying such policies. Again, this
debate is far from over, and depending on how it is
decided could have a significant impact on the timely
availability of assisted dying in jurisdictions that have
decriminalized it.
At Bioethics we would be delighted to receive submis-
sions addressing any of these issues.
UDO SCHUKLENK