To describe Switzerland as a Mecca for suicide tourism is hyperbole, but suicide facilities would draw as many people as yodelling and cowbells. The Australian euthanasia activist, Dr Philip Nitschke, is even engaging a travel agent to buy one-way tickets to Zurich for members of his organisation, Exit International. The agency would also handle all the paperwork required by the assisted suicide clinic run by Dignitas.
"They need medical records to explain how sick they are, proof of residence, passports and certified extracts of birth certificates," Dr Nitschke told News.com.au. "People who are that ill, if they are thinking of making this journey, it's a lot of work and almost impossible for them. They also need supportive letters from family members." The service will cost about A$1000.
It also emerged this week that an unnamed 83-year-old man became the first Briton to end his life at Dignitas because he was in the early stage of dementia. A leading campaigner for assisted suicide in the UK, Michael Irwin, helped get a psychiatric evaluation earlier this year for him. He told The Independent that “He was a sensible, professional person in the early stages of dementia and knew what dementia will involve. The family are very pleased that it all happened the way he wanted it, with dignity.”
Mr Irwin is a well-known figure in the UK who has helped a number of people to die. Although he has never been arrested, in 2005 he was struck off the medical register for serious professional misconduct after he helped a fellow euthanasia campaigner to commit suicide. According to the London Times he foresees that there will be many more visitors to Dignitas as the number of people with dementia rises.
What is the position of the law on assisted suicide in Switzerland? Journalists often make the mistake of asserting that euthanasia is allowed there. This is not true: only assisted suicide – but this has been legal, astonishingly, since the 1930s. A review article in the Cambridge Quarterly of Healthcare Ethics by Roberto Andorno, of the Institute of Biomedical Ethics of the University of Zurich, describes how Switzerland gradually became magnet for foreigners who want to commit suicide.
Article 115 of the 1937 Swiss Penal Code states that: “Every person who, for selfish reasons, incites or assists someone to commit suicide, shall be sentenced to imprisonment of up to five years or a fine.” It was very far from the minds of the legislators of the time to promote assisted suicide. They seem to have had in mind situations like Goethe’s novel, The Sorrows of Young Werther -- “romantic stories about people committing suicide in defence of their own, or their family’s honour, and about suicides committed by rejected lovers.”
Thus the legislators left two wide gaps in the law. First, no doctor need be involved, and second, there need be no medical condition. Ultimately this gave rise to a number of non-profit assisted suicide agencies. The leading ones are Dignitas, with 5,500 members, and two branches of the group Exit, for French-speakers (10,000 members and German-speakers (55,000 members).
Attempts to regulate the growth of the assisted suicide industry have largely failed. With the law phrased so loosely, the only certain criterion is that the person requesting help must be mentally competent. In 2009 a psychiatrist was convicted for being reckless in helping two people with mental illness to commit suicide.
In 2011 the government decided that further regulation was largely futile. A total ban was politically impossible and amending the law might make the situation worse. Among other disadvantages it might legitimize the suicide organisations. Instead, the government has decided to promote palliative care and to campaign against suicide.
Daniel Callahan has again been chastised for his view that obesity should be stigmatized. Whilst most attacks have been from mainstream journalists, the latest critiques come from respected ethicists. In the most recent edition of the Hastings Centre Report two bioethicists argue that Callahan's approach is "a failed and ethically dubious strategy".
The authors, Daniel S. Goldberg, of East Carolina University, and Rebecca M. Puhl, of Yale University, cite studies demonstrating the ineffectiveness of stigmatizing obesity. They state that: "there is consistent evidence that individuals exposed to weight stigmatization are vulnerable to numerous adverse health consequences, including depression, anxiety, low self-esteem, suicidal ideation, and avoidance of health care." Research also indicates that public health campaigns containing messages that stigmatize and shame obese persons actually induce less motivation and lower intentions to improve.
The authors believe that stigmatization is morally wrong, regardless of its efficacy: "even if stigma produced extremely salubrious consequences, we think it should not be deployed as a public health intervention. The intense harms stigma can impose and the way it can literally spoil identity provide a powerful argument against its usage regardless of the consequences."
Goldberg and Puhl's article is just one of six commentaries published in this month's Hastings Centre Report review, all of which question Callahan's view.
Ethicists like to think of themselves as morally good people. But a recent article in the journal Metaphilosophy questions this.
The article, by Joshua Rust and Eric Schwitzgebel of the University of California Riverside, compares the responsiveness of ethicists and non-ethicists to student emails. Though the vast majority of ethicists said failing to respond to emails was morally bad, few were above average in their response rate. The survey found the response rates of ethicists to be 62%, not significantly different from the response rate of 58% among non-philosophers. The researchers also found that many of the ethicists were deluded about their rates of responsiveness: "professors who claimed to reply to at least 98 percent of student e-mails replied to an average of 64.3 percent of the e-mails we sent," they reported.
This undermines the notion of 'moral intellectualism' - the view that an education in morality is sufficient to ensure morally good behaviour. If ethicists are no more likely to act in a moral way the connection between ethical education and moral behavior is weaker than many philosophers have thought. Nevertheless, Schwitzgebel and Rust were circumspect: "It is far too soon, we think, to say that such a starkly negative view of philosophical ethics is compelled by the psychological data".
Approximately half of American ethicists believe that professional ethicists behave at least a little morally better than non-ethicists, Schwitzgebel and Rust said.
The researchers have produced similar studies before. One previous study found that philosophy books dealing with ethics were more likely to be missing from leading academic libraries than similar non-ethics books in philosophy. Two other studies found that ethicists behaved no more courteously than non-ethicists and were as likely to avoid paying registration fees as non-ethicists at conferences of the American Philosophical Association.
A recent study has indicated that medical students are not retaining the ethical terms taught to them in ethics classes. The report, published in the journal AJOB Primary Research, involved interviews with 109 students of the University of Iowa Carver College of Medicine.
The students, all third years, were asked about the ethical terminology taught to them in first and second year. Many could remember the four basic ethical principles they were taught (beneficence, non-maleficence, respect for patient autonomy and justice), but few could remember the six sources of ethical value or categories for justifying an ethical decision (ethical principles, rights, consequences, comparable cases, professional guidelines and conscientious practice). Overall, 59.6% of the students remembered all four principles, but the highest number of sources of ethical value recalled was four of the six. Only 10% of students could name three or four of the six sources.
Researchers also found that students were not likely to use the terms they had learned when asked to reflect on ethical situations they had encountered.
Many experts believe that there needs to be more ethical education at a practical clinical level if students are to retain the information. “I would really encourage [faculties] to think about how to integrate ethical education also into the clinical realm,” said Dr Lauris Kaldjian, principal author and director of bioethics and humanities at the University of Iowa Carver College of Medicine.
One question yet to be answered is whether the concepts, not just the terminology, have been lost on the students.
The 'yuk' factor can sometimes play a decisive role in our moral assessments. But how reliable a guide are our visceral reactions of disgust? This question has become one of the most popular topics of research in the field of moral psychology.
Many academics around the world now call themselves 'disgustologists' - experts in the science of disgust. One such expert, Val Curtis of the London School of Hygiene and Tropical Medicine, was interviewed on the BBC recently. Curtis believes that disgust is a evolved emotional trait by which we instinctually avoid things we believe could be carrying disease: "[One clear function is that] it keeps us out of things that might have an infectious disease."
According to Curtis these same visceral reactions of disgust carry over into our moral assessments. Sometimes this is a useful thing, sometimes not: "A part of our moral disgust we need to listen to... because it can help the moral framework of society on the other hand, part of our history is to shun those who are outsiders... we need to recognize that we may be feeling disgust for those who are outsiders and overrule it."
Conservative bioethicist Leon Kass famously claimed in a 1997 article that reactions of disgust can in sometimes be a very good moral guide: "in crucial cases... repugnance is the emotional expression of deep wisdom, beyond reason's power fully to articulate it." As examples of this he quoted our disgust at incest or cannibalism.
However, very few ethicists today subscribe to Kass's theory. In a recent interview with the BBC Australian philosopher Steven Clarke dismissed Kass, saying that he sees "no convincing reason to think that disgust or any other emotion give us a profound insight into moral truth".
Politicians in the Netherlands are pushing the organisation which represents Dutch doctors to overcome its misgivings over euthanasia for patients with dementia.
The Dutch euthanasia law clearly allows euthanasia for demented patients who have left an advance directive. The number of these cases is climbing rapidly. In 2010 there were 25; in 2011, the figure was 49.
But doctors are reluctant to approve these requests because they are not sure whether the patient would really want to die. A spokesman for the KMG says, “As a doctor you must understand what the patient really wants. Communication is essential if you are to be convinced as a doctor of the seriousness of the suffering at that moment.”
The Dutch Medical Association (KNMG) now wants to amend the law. It contends that the doctor who gives a second opinion – which is legally required -- must both see and communicate with the patient.
But medical ethicists and government officials feel that the KNMG is being obstructionist. Former health minister Els Borst, who was responsible for the euthanasia law, says: “A professional body cannot choose its own interpretation of the law.”
The government has set up a working party to clarify whether advanced directives suffice for euthanasia. It will report in six months’ time.
The bill was signed into law by governor Peter Shumlin on Monday. Vermont’s House passed the bill 75-65, after its passage through the Senate earlier this month.
The new law has had a mixed reception. Bob Ullrich, of Patient Choices Vermont said that “it means peace of mind and comfort to a lot of people… to know every day of your life that it’s there should such an occurrence happen.” Kathryn Tucker of Compassion and Choices told reporters that "support for patients to be empowered and choose aid and dying is growing… I think this is an important step in moving that forward."
But anti-euthanasia groups have expressed grave concern about the bill.“We now have state-sanctioned suicide in Vermont,” said Edward Mahoney of the Vermont Alliance for Ethical Healthcare.
The new law does not require hospitals to offer euthanasia. It requires at least two doctors to make the medical determination whether or not a patient qualifies for physician-assisted suicide. A patient wishing to end his life must make an initial oral request at least 15 days before receiving lethal drugs, and a written and oral request to die 48 hours before receiving them.
The Australian winner of the 2009 Nobel Prize in Medicine is leveraging her discovery to market a test which will help people know their true health status and biological age.
Elizabeth Blackburn won her award, along with two other researchers, for her work on telomeres, pieces of DNA which cap chromosomes and keep cells from ageing too soon. She discovered the telomerase enzyme which repairs the telomeres. Long telomeres are associated with longer life expectancy; short telomeres with shorter life expectancy.
She says that it is impossible to predict how much longer people have to live, but shorter telomeres may indicate bad health. Telomere length is associated with stress, for instance. Doctors could intervene earlier to prevent disease. Dr Blackburn has said that her discovery "sort of translates into a fountain of youth; the number of years of healthy living is related to telomere length. We don't think clocks will be turned back, but it is a question of whether we will extend our health span."
Full of enthusiasm, Dr Blackburn has helped formed a company, Telome Health, to market a test for telomere length.
But a controversy is brewing over whether the test is premature. Carol W. Greider, who shared the Nobel Prize with her, feel that the test is premature. Peter Lansdorp, another expert on telomere biology, told Macleans that he was sceptical. “It’s too early, and it’s not supported by scientific data.”
One problem is that interpreting the results is difficult because there is so much individual variability. A report of short telomeres could put patients on a merry-go-round of more and more tests to discover what the original test meant. “You worry about that,” she told the New York Times. “But that’s not the fault of the test, is it? That’s the fault of the way medicine is practiced. Let’s not blame the messenger here.”
“Alzheimer’s has been portrayed as the ‘disease of the century’ that is poised to have a near catastrophic impact on the world’s healthcare system as the population ages,” Professor Johnstone said.
“This representation of the disease—along with other often used terms such as ‘living dead’, a ‘funeral that never ends’ and a ‘fate worse than death’—places Alzheimer’s as a soft target in the euthanasia debate because it plays to people’s fears of developing the disease and what it symbolises. It positions Alzheimer’s as something that requires a remedy; that remedy increasingly being pre-emptive and beneficent euthanasia.”
Professor Johnstone acknowledges that euthanasia is a polarising and emotive issue, however she warns that the public could be unduly swayed by the way the media, and pro-euthanasia groups, to frame the issue as “simply a matter of choice” through the use of highly personalised, individual experiences.
“Euthanasia is far from a simple matter of choice, as choice itself is no simple matter; it is an extremely complex phenomenon. And Alzheimer’s disease cannot be adequately portrayed through highly publicised individual cases.”