Is there any difference between euthanasia and palliated starvation?


Xavier Symons

While euthanasia and assisted suicide are currently illegal in most countries, the practice of voluntarily stopping eating and drinking (VSED) is seen by some as an ethically and legally permissible alternative. VSED refers to seriously-ill patients refusing to eat and drink for a sustained period of time with the intention of bringing about their own death.

Yet a new paper published in BMC Medicine argues that VSED is ethically indistinguishable from assisted suicide, and should be subject to the same legal regulations as more salient cases of assistance in dying.

The paper, lead-authored by Ralf J. Jox of the Institute for Ethics, History and Theory of Medicine at the University of Munich, argues that “supporting patients who embark on VSED amounts to assistance in suicide, at least in some instances, depending on the kind of support and its relation to the patient’s intention”.

While VSED does not involve an invasive or aggressive act like many other means of suicide, the authors write that “VSED should [nevertheless] be considered as a form of suicide, as there is both an intention to bring about death and an omission that directly causes this effect”. Doctors who assist patients in VSED — by encouraging them, or promising pain-relief if VSED is undertaken — are potentially instrumental in the deaths of the patients, as the suicide would not occur without them, and they share the patient’s intention of inducing death.

The authors of the paper conclude that the same legal prescriptions or regulations that apply to physician assisted suicide should also apply to VSED.

“[We] maintain… that future ethical discussions on assisted suicide require consideration of medically supported VSED, and vice versa…Thus, the widely held position by palliative care societies, professional bodies of physicians, legal scholars, and ethicists to disapprove of assisted suicide but approve of and even promote medically supported VSED appears inconsistent”.

This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.


Accessed 2017-08-11


Contraceptive Coverage and the Balance Between Conscience and Access

Ronit Y. Stahl,PhD; Holly Fernandez Lynch, JD, MBE

When the Obama administration included contraception in the essential benefits package to be covered by employer-sponsored health insurance plans under the Affordable Care Act, it sought to preserve access for women while addressing the concerns of employers with religious objections. Although the accommodations and exemptions were not enough for some employers, balance was the ultimate goal. This also was reflected in Zubik v Burwell, the Supreme Court’s most recent decision on the matter; on May 16, 2016, the justices remanded the litigants to the lower court so they could be afforded the opportunity to reach a compromise between religious exercise and seamless contraceptive coverage. No further compromise was forthcoming.

Now the Trump administration has rejected balance as a worthwhile goal.1 Its new contraceptive coverage rules, released on October 6, 2017, prioritize conscientious objection over access.2,3 The rules take effect immediately, and new legal challenges, this time on behalf of patients rather than objecting employers, have already begun.4 The new rules preserve the default requirement that employers must include free access to contraceptives as part of their insurance plans. However, the rules now exempt employers with religious or moral objections to contraceptives, without requiring any alternative approaches to ensure that beneficiaries can obtain contraceptives at no cost.2,3
[Full Text]

Stahl RY, Lynch HF. Contraceptive Coverage and the Balance Between Conscience and Access. JAMA. Published online October 19, 2017. doi:10.1001/jama.2017.17086

The Hidden Professions of Conscientious Objection

Bob Parke*

Federal legislation permitting the killing of people who meet the criteria for Medical assistance in dying (MAiD) has challenged most healthcare professionals to carefully consider where they morally stand on causing someone’s death. While many healthcare providers may feel it is against their values to participate in euthanasia, we have all been asked or will be asked at some point about euthanasia by a patient or their family. . . .  In general, frontline conscientious objectors have been respected and accommodated. But, what about those behind the scenes? . . .[Full text]

Dignitarian medical ethics

Linda Barclay


Philosophers and bioethicists are typically sceptical about invocations of dignity in ethical debates. Many believe that dignity is essentially devoid of meaning: either a mere rhetorical gesture used in the absence of good argument or a faddish term for existing values like autonomy and respect. On the other hand, the patient experience of dignity is a substantial area of research in healthcare fields like nursing and palliative care. In this paper, it is argued that philosophers have much to learn from the concrete patient experiences described in healthcare literature. Dignity is conferred on people when they are treated as having equal status, something the sick and frail are often denied in healthcare settings. The importance of equal status as a unique value has been forcefully argued and widely recognised in political philosophy in the last 15 years. This paper brings medical ethics up to date with philosophical discussion about the value of equal status by developing an equal status conception of dignity.

Barclay L. Dignitarian medical ethics. Journal of Medical Ethics Published Online First: 13 October 2017. doi: 10.1136/medethics-2017-104467

Health professionals’ pledge rejects any form of participation in or condoning torture

Sean Murphy*

Physicians for Human Rights is sponsoring a Health Professionals’ Pledge Against Torture that includes statements that signatories will never “participate or condone” torture and support colleagues who “resist orders to torture or inflict harm.”  It also commits signatories to insist that their professional associations support those facing pressure “to participate or condone torture and ill-treatment.”

What is noteworthy is that the pledge is not limited to simply refusing to torture someone, but is a pledge against participation (which would include forms of facilitation like referral) and against condoning the practice.

Replace “torture” with commonly morally contested procedures and it becomes obvious that the ethical position taken by Physicians for Human Rights vis-à-vis torture is identical to the position of many health care professionals who object to practices like euthanasia or abortion for reasons of conscience.

Conscientious objection: Can a hospital refuse to provide treatment?

Baylor College of Medicine

Claire Horner

Canada recently legalized medical assistance in dying (MAiD), which allows patients to receive a lethal drug that they can self-administer, or be administered a lethal drug by an authorized clinician with consent of the patient. As provinces and territories work to create and clarify legal guidelines for providing MAiD, many Catholic hospitals have refused to offer it, citing opposition to physician-assisted suicide and euthanasia in Catholic moral teaching.

This controversy surrounding institutional conscience-based refusals raises an important question: Should a health care institution have the right to refuse to provide a particular treatment for conscience-based reasons? . . . [Full text]

There is no defence for ‘Conscientious objection’ in reproductive health care


A widespread assumption has taken hold in the field of medicine that we must allow health care professionals the right to refuse treatment under the guise of ‘conscientious objection’ (CO), in particular for women seeking abortions. At the same time, it is widely recognized that the refusal to treat creates harm and barriers for patients receiving reproductive health care. In response, many recommendations have been put forward as solutions to limit those harms. Further, some researchers make a distinction between true CO and ‘obstructionist CO’, based on the motivations or actions of various objectors. This paper argues that ‘CO’ in reproductive health care should not be considered a right, but an unethical refusal to treat. Supporters of CO have no real defence of their stance, other than the mistaken assumption that CO in reproductive health care is the same as CO in the military, when the two have nothing in common (for example, objecting doctors are rarely disciplined, while the patient pays the price). Refusals to treat are based on non-verifiable personal beliefs, usually religious beliefs, but introducing religion into medicine undermines best practices that depend on scientific evidence and medical ethics. CO therefore represents an abandonment of professional obligations to patients. Countries should strive to reduce the number of objectors in reproductive health care as much as possible until CO can feasibly be prohibited. Several Scandinavian countries already have a successful ban on CO.

Fiala C, Arthur JH. Eur J Obstet Gynecol Reprod Biol. 2017 Jul 23. pii: S0301-2115(17)30357-3. doi: 10.1016/j.ejogrb.2017.07.023. [Epub ahead of print]


La conscience et les médecins canadiens


Collectif des médecins contre l’euthanasie

Depuis la légalisation de l’euthanasie, il y a un an, nous voyons qu’il y a une forte pression politique pour normaliser sa pratique au Canada. Pourtant, beaucoup de médecins s’opposent toujours à cette pratique. Nombre d’entre eux désireraient qu’elle soit rigoureusement restreinte. Et plusieurs, pour des raisons de conscience, personnelle ou professionnelle, refusent catégoriquement d’y collaborer.

Malheureusement, nos politicien(ne)s ne nous permettent aucun doute quant à leur intention d’ignorer le jugement des médecins dissidents, et d’étouffer leur opposition. Or, les pires de ces politiciens semblent se trouver parmi les rangs de notre propre profession.

Considérons, à titre d’exemple, la nouvelle politique (2015), du College of Physicians and Surgeons of Ontario, au sujet du « Droit de Conscience » de ses membres.

Cette politique est identifiée comme étant une simple mis à jour révisée, mais en réalité elle s’apparent peu à la version précédente (2008).

Et la raison en est évidente : sans jamais parler franchement de l’euthanasie, du suicide assisté, ou même de l’aide médicale à mourir, cette nouvelle politique fut, dès le départ, façonnée pour faciliter une redéfinition radicale, à la manière Orwellienne, de « l’euthanasie », de l’homicide en soin médical. Cela oblige, effectivement, tous les médecins ontariens à participer au programme d’euthanasie.

De manière pratique :

« Dans le cas où des médecins ne voudraient pas fournir certains soins pour des raisons de conscience ou de religion, ces derniers sont tenus de référer le patient à un autre fournisseur de soins. »

Bien-sûr, on voit, ici, l’obstacle principal à la collaboration de nombreux docteurs qui considèrent le fait d’orienter leurs patients vers d’autres agences de mort  comme étant aussi horrible que de pratiquer eux-mêmes l’acte d’euthanasier.

Cependant, le problème éthique ne s’arrête pas à  l’obligation de référer le patient à d’autres ressources. Il y a également le « devoir d’informer » :

« Les médecins doivent fournir de l’information à propos de toutes les options cliniques qui peuvent être disponibles ou appropriés pour répondre aux besoins cliniques du patient ou à ses préoccupations ».

« Les médecins ne doivent pas retenir de l’information au sujet d’une procédure ou d’un traitement pour des raisons de conflit avec leur conscience ou leur croyance religieuse ».

Prenez bien note des italiques ajoutés : apparemment, le médecin se trouverait dans l’obligation d’informer ses patients de toutes les options légalement disponibles, même si elles s’avèrent inappropriées ! Et cette obligation aurait préséance sur toute conviction morale ou professionnelle du médecin.

L’aspect impératif de ce “devoir d’informer” dépasse même celui du « devoir de référer”. Dans chaque cas où les critères associés à l’euthanasie seraient satisfaits, il y aurait obligation de soumettre le patient aux terribles stress et doutes soulevés par le constat, ainsi imposé, qu’il fait partie du groupe select de personnes pour lesquelles l’euthanasie est devenue praticable. Aucune objection de jugement, aucune objection de conscience, ne pourrait excuser le médecin du devoir de livrer ce message effroyable, avec la suggestion implicite qu’il véhicule.

En Ontario, donc, par proclamation du CPSO, le rôle du médecin serait réduit à celui d’une machine distributrice automatique qui afficherait les options d’euthanasie mandatés par l’état, et qui offrirait passivement de boutons correspondants que le patient puisse actionner.

Évidemment, la force et l’étendu d’un telle politique sont extraordinaires. Le jugement professionnel est la fondation de la pratique médicale. Le « Droit de Conscience » est à la base de tout notre système de démocratie séculaire. Tous les deux sont écartés. Nous devons réellement nous trouver devant une situation de crise colossale pour justifier de telles mesures draconiennes !

Mais voilà. Il n’existe aucune urgence semblable.

Rappelons-nous que le programme original d’euthanasie nous fut vendu comme la réponse impérative au sort de ce patient hypothétique, au seuil de la mort et affligé de souffrances, à la fois, insoutenables et intraitables. Rappelons aussi, comment ce cas extrême, que dis-je, ce cas virtuellement mythique, fut exploité pour nous acheminer doucement vers tous ces morts, sans rapport, que nous devons craindre actuellement. Encore, de nouveau, une stratégie similaire se poursuit. Cette fois, le besoin absolu, pour tous les médecins, de faire la promotion de l’euthanasie (en tout temps et auprès de leurs patients les plus vulnérables), nous est présenté comme le prix nécessaire pour pallier à la possibilité hypothétique qu’un seul patient puisse être frustré dans son désir de mourir.

On nous demande de croire que n’importe quel fardeau réel, qu’il soit financier, professionnel ou moral, serait justifié quand il est question de faciliter une seule mort volontaire et idéalisée. Ce serait un genre d’inversion grotesque de la proposition voulant que « aucun prix n’est trop élevé, pourvu qu’un seul enfant puisse vivre… », qui devient dans la discussion actuelle : « pourvu qu’une seule personne puisse mourir… »

D’autres juridictions, pas moins respectables que l’Ontario, ont épousé des principes tout à fait opposés. Et il n’existe aucune évidence que quiconque aurait souffert, ou souffrira ultérieurement.

Le Manitoba élabore actuellement une loi qui reconnaitrait explicitement le droit de non-participation et de non-orientation des patients vers l’euthanasie pour les médecins, ainsi que pour les autres professionnels de la santé. Deux des principaux hôpitaux de Winnipeg ont signalé leur refus de permettre l’euthanasie dans leur établissement.

Dans l’État de Vermont, une bataille judiciaire autour des mêmes principes s’est soldée, dernièrement, par une victoire complète des droits des médecins.

Et en Ontario, un groupe de médecins, dévoués et courageux, a récemment engagé une action à ce sujet contre le CPSO; les arguments furent écoutés Juin 13-15, 2017.

Ce jugement sera rendu plus tard dans l’année. Nous espérons que la cour tranchera, cette fois, du bon côté !

Mais nonobstant la nature de ce jugement, le temps qu’il faudra, la dépense; nonobstant les efforts législatifs qui peuvent être éventuellement exigés : Cette politique autoritaire du College of Physicians and Surgeons of Ontario n’est ni nécessaire, ni justifiée. Elle n’est pas désirable. Elle n’est même pas raisonnablement défendable. Elle est extrême. Elle est irrationnelle. Surtout, elle serait profondément préjudiciable pour les médecins,  leurs patients, et tout le système médical. Elle représente une injustice et une honte qui ne peuvent être acceptées.


Conscience and Canadian doctors


Physicians’ Alliance Against Euthanasia

In the year since euthanasia became legal, we have witnessed a powerful political push to normalize it as part of medicine in Canada. Yet many doctors remain opposed to the practice. Most would like to see it rigorously limited. And some, for reasons of personal and/or professional conscience, refuse categorically to be part of it.

Unfortunately, our politicians have made it perfectly clear that they intend to ignore the judgement of opposing doctors and to stifle their dissent. In fact, the worst of these politicians are to be found within our own profession.

Consider, as a case in point, the new (2015) College of Physicians and Surgeons of Ontario policy on doctors’ conscience rights.

This CPSO policy is identified as a mere “revised update”, but it actually bears little resemblance to the earlier version (2008).

And it is obvious why this is so: Without ever honestly mentioning euthanasia, assisted suicide, or even MAID, the new policy was designed from the start to facilitate a radical new Orwellian redefinition of “euthanasia”, from homicide to medical treatment. It effectively obliges all Ontario physicians and surgeons to participate in the euthanasia program.

In practical terms:

“Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health-care provider must be provided to the patient.”

This, of course, is the main sticking point for many doctors, who consider referring their patient to any agency of death to be an act just as abhorrent as performing the euthanasia themselves.

But “effective referral” is by no means all. There is also the “duty to inform”:

“Physicians must provide information about all clinical options that may be available or appropriate to meet patients’ clinical needs or concerns.”

“Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.”

Please note the italics: The physician apparently has a duty to inform his patients of all options legally available even if they are inappropriate! And this obligation shall override any moral or professional convictions that physician might hold.

The violence of the obligation to “inform” goes even beyond that of “effective referral” itself. Every patient who fits the criteria for euthanasia must be subjected to the terrible stress and doubt of learning that he or she belongs to that select group of people for whom medically-inflicted death has become an option. And no objection of judgement or of conscience can free the doctor from delivering that terrible message and its implicit suggestion.

In Ontario, then, by proclamation of the CPSO, the doctor’s role is reduced to that of an automatic vending machine which simply displays state-mandated euthanasia options and passively offers corresponding buttons for the patient to push.

Obviously, the scope and impact of such a policy is astounding. Professional judgement is the bedrock of medical practice. Freedom of conscience is the underpinning for our entire system of secular democracy. Both are set aside.  The scale of the emergency must be colossal to require such draconian measures!

But, of course, there is no such urgency.

Let us remember that the original euthanasia program was sold to us as an imperative response to a hypothetical terminally ill patient in unbearable and untreatable pain.  Let us recall how that extreme, no, that virtually mythical case, was leveraged into all of the totally unrelated deaths that we now apprehend. Once again, a similar strategy is at work. This time, the absolute need for all doctors to promote euthanasia (all the time and to all of their most vulnerable patients), is presented as a required response to the hypothetical possibility of even one patient, desirous to die, but who is frustrated in her wish.

We are asked to believe that any real burden whatsoever, financial, professional, or moral, can be justified in the interest of allowing that one sacred voluntary death. It is a sort of grotesque inversion of the proposition that “no price is too high” provided that “only one child be saved…”.  Which becomes in this case: “if only one person might die…”.

Other jurisdictions, no less respectable than Ontario have taken an opposite stance, and there is no evidence that anybody has suffered or will suffer.

Manitoba is in the process of explicitly recognizing the right of non-participation and non-referral of all health professionals and others working in health care. Major hospitals in Winnipeg have announced their refusal to euthanize patients.

In the State of Vermont a judicial battle over similar issues has resulted in an unambiguous victory for doctors’ rights.

And in Ontario, a group of dedicated and courageous doctors launched a court challenge in defense of doctors’ conscience, which was heard June 13-15, 2017.

That judgement will be rendered later this year.  Let’s hope our courts get it right this time!

But regardless of that outcome, regardless of the timeframe, and regardless of expense; regardless of the legislative efforts that may ultimately be required: This authoritarian policy of the College of Physicians and Surgeons of Ontario is neither necessary nor justified. It is not desirable. It is not even reasonably defensible. It is extreme. And it is irrational. Above all, it is profoundly harmful to individual doctors and patients and to the whole medical profession. It constitutes both an injustice and an embarrassment which cannot be allowed to stand.


Why I don’t support conscientious objection to MAID


Lesley Barron

Bill 84 has been passed into law in Ontario and outlines the legal issues surrounding medical aid in dying (MAID), which has been legal in Canada since last year. The patient’s death must be “reasonably foreseeable” and their suffering “grievous and irremediable” to qualify for the service. Groups such as those with advance directives, mental illness, and minors are left out, and whether they should be allowed access to this service in the future is an issue for another time.

One of the most contentious aspects of Bill 84 is the requirement for the treating physician in Ontario to provide a referral for a patient who has requested MAID to a physician who provides it. . . [Full text]