The Role of Medical Ethics in the Practices of Assisted Dying

An increasing number of countries worldwide are regulating practices of ‘assisted dying’, in particular (physician-) assisted suicide and euthanasia. While a huge amount of research has been conducted on the various ethical, legal, and social aspects of assisted dying, one issue stands out: the role of medical ethics expertise and ethics support in these practices has not yet been addressed in depth. Although laws and professional codes of practice may provide a framework of legitimacy for assisted dying, many ethical questions remain regarding concrete practices in this context. In some countries, explicit ethical expertise has already been incorporated into the regulations. In the Netherlands, for instance, the five regional euthanasia review committees comprise physicians, ethicists, and legal experts. These committees assess situations retrospectively and decide whether physicians who performed euthanasia or assisted suicide complied with the statutory due care criteria. While in the aforementioned case, ethicists are involved to analyse cases from a retrospective perspective, more and more often, clinical ethicists are also involved prospectively in cases of requests for assisted dying. Ethical experts have become an integral part of clinical care, for example, as members of clinical ethics support services, whose aim is to support healthcare personnel in dealing with ethical challenges in clinical practice. They are often requested to support healthcare teams in difficult decision-making processes, such as the withdrawal of life-saving treatments. Situations involving decision-making at the end of life are a key focus of ethical counselling. As mentioned, in some healthcare institutions in Switzerland and Canada, clinical ethics consultants are called upon to evaluate whether assisted dying can be accepted by a healthcare institution in a given case. In Germany and Austria, where assisted suicide has recently been decriminalised, medical ethicists are increasingly being asked to assist with institutional policies and the training of healthcare professionals regarding assisted suicide. Right-to-die associations also offer assistance in suicide in Switzerland and Germany. These associations often have internal ethical commissions that develop internal ethical and procedural guidelines. These examples raise the question of whether medical ethics expertise and support should be viewed as in institutional requirement when it comes to assisted dying. However, these practices have rarely been systematically analysed. It is unclear what goals ethicists should pursue in this context, what professional role and identity they should adopt, and what competencies they need to fulfil their role. One focus of the debate, which is addressed by a number of contributions in this special issue, is to clarify which ethical needs and competences are relevant when dealing with requests for assisted dying. While there may be numerous ethically relevant issues in the context of such requests, it is necessary to be precise with regard to which of these ethically relevant issues should be tackled by ethics support services. Moreover, and this is particular relevant in light of the broad range of competences attributed to clinical ethicists, there is need to clarify which ethical competences are needed for dealing with requests for assisted suicide and how such competences are distinguished from more general competences, for example, in communication. To provide an example: Ethics consultants may be experts in facilitating a multiprofessional case discussion, but such expertise may not qualify them to be the best choice for facilitating any case discussion taking place in the context of assisted suicide. A second, more fundamental focus also touched upon in this issue is whether beyond the analysis and clarification of ethical issues, medical ethicists may contribute anything to concrete cases of requests. Given the controversial theoretical debate and incompatibility of existing normative positions one may argue that it is simply not possible to assist with recommendation or decision making in these cases. It is well known that there has been considerable criticism regarding the work of clinical ethicists who, for example, are or seem closely involved with the practice of assisted dying by those who disagree with this practice on normative grounds. At the same time, it may be considered ethically problematic to stay away from concrete cases and limit the ethicist's work to unsolved normative issues. The aim of this special issue is therefore to gain empirical insights into how ethical expertise is currently understood and implemented in assisted dying practices; to clarify the concept of ethical expertise in assisted dying; and to address the differences between ethical, legal, and philosophical expertise, critically reflecting on and discussing the role of ethical experts in assisted dying practices. The contributions to this special issue include philosophical and conceptual works, the results of empirical studies, and discussion papers. As with any ethically controversial topic this thematic issue probably raises more (new) questions than it provides answers. We still hope that some of the work collated in this edition will be relevant for the further debate. Finally, we would like to thank all researchers who have submitted work for this special issue, not only for their scholarship but also for their patience. We would also like to thank all reviewers for the valuable feedback. Last but not least, we thank the editors for accepting our proposal for this special issue and Clancy Pegg for her continuous support during the whole editorial process

Assisted suicide · Bioethics · Clinical Ethics · Ethical code · Harm · Health care · Informed consent · Legitimacy · Medical ethics · Statutory law · Ethics in medical practice · Organ Donation and Transplantation · Palliative Care and End-of-Life Issues