Maintaining the proper physician-patient relationship in health care is vital to the well-being of patients, especially when considering end of life decisions such as euthanasia. Because this topic has been in the forefront of media in recent years, there appears to be a need to understand how the relationship between physician and patient works in these practical situations, as well as understand what the most appropriate model of patient care is in regards to maintaining patient autonomy. However, before this can be done this paper will begin with a brief look at the overall permissibility of euthanasia, using the arguments of Dan Brock and Leon Kass. Once the issue of permissibility is discussed, I continue by investigating three main models of patient care presented by Linda and Ezekiel Emanuel: informative, interpretive, and deliberative. Each of these models presents a different view of patient autonomy that changes how the physician and patient interact. By discussing the philosophical requirements of autonomy presented by philosophers such as Harry Frankfurt, Susan Wolf, and Andrea Westlund, I argue that the deliberative model of patient care provides the most sufficient view of autonomy while also protecting the physician-patient relationship and patient well-being.

In a country such as Australia which claims adherence to democratic values, it would appear important that policies and laws on such a controversial and value laden issue as active voluntary euthanasia (AVE), need to have at least some basis in public opinion and in that of relevant professional groups. It has been argued that public opinion may be of limited value due to the public's lack of experience and exposure to this issue. The opinions of people with more exposure to and reflection on the ethical issues surrounding euthanasia need to be ascertained. Nurses are one group who have prolonged involvement with the care of dying or suffering people and their families. Nurses in the Australian Capital Territory (ACT) could be a particularly well informed group because of the ongoing open debate resulting from four proposed laws on AVE in this Territory since 1993. The overall purpose of this thesis was to identify the attitudes of nurses in the ACT towards AVE. This thesis was supported by a study which provided information on four aspects of nurses' attitudes towards AVE. Firstly, the attitudes of registered nurses in the ACT were compared to those of other nurses, medical practitioners and members of the general public in Australia. Secondly, the associations between characteristics of the nurses and their attitudes were investigated. Thirdly, the legal conditions which nurses believe should be in a law allowing active voluntary euthanasia were identified. Finally, the arguments nurses put forward to support their attitudes towards AVE were analysed This thesis does not attempt to evaluate the ethical arguments proposed, merely to reflect the views put forward. A postal survey was carried out in late 1996 of 2000 randomly selected registered nurses from the Australian Capital Territory. Responses were received from 1218 nurses (61%). Attitudes of Nurses: A majority of nurses who responded, supported AVE as "sometimes right", be it homicide by request (72%) or physician assisted suicide (71%). A slightly smaller majority of nurses believed the law should be changed to allow homicide by request (69%) and physician assisted suicide (67%) under certain conditions. If AVE were legal, 66% of the nurses indicated they were willing to be involved in the procedure. Only 30% were willing to assist patients to give themselves the lethal dose, while 14% were willing to administer the lethal dose to the patient. Comparing these results with previous surveys, it appears that nurses are less in favour of AVE than the general public but more in favour than medical practitioners. Associations between Characteristics of Nurses and Attitudes: Those nurses who were more likely to agree that the law should allow AVE, were under the age of 40 years, agnostic, atheist or of the Anglican religion, to have less contact with terminally ill patients, to work in the area of critical care or mental health, and to take less interest in the issue of AVE. Palliative care nurses were the only subgroup without a majority in favour (33%). There is other evidence in the euthanasia literature indicating that nurses and doctors are less in favour of AVE than the general public. Taken together with the present findings, it may be concluded that attitudes towards AVE are more favourable in people who have less contact with the terminally ill. Legal Conditions in an AVE Law: The conditions most strongly supported in any future AVE law were "second doctor's opinion" (85%), "cooling off period" (81%), "patient must have unbearable protracted suffering" (80%), "doctor must inform patient about illness and treatment" (78%) and "patient must be terminally ill" (63%). There was only minority support for "patient not suffering from treatable depression" (42%), "patient administers or assists to administer, the fatal dose themselves" (32%) and "patient over a certain age" (7%). Support for a change in the law to allow AVE was 38% for a young man with AIDS, 39% for an elderly man with early stage Alzheimer's disease, 44% for a young woman who had become quadriplegic and 71 % for a middle aged woman with metastases from breast cancer. Arguments Supporting AVE Attitudes: The most common argument in support of AVE was that people should have the right to control their own lives and thus be able to decide for themselves when and how they wanted to die. The most common argument against AVE was that of the slippery slope in which it is feared that the boundaries which society puts on killing will be extended. Conclusions: This inquiry pinpoints the discordance between attitudes towards AVE and the legal status of AVE. Parliamentary representatives need to consider the current attitudes of their constituents, and especially those of relevant health care professionals towards AVE. It is important that a nursing perspective is represented in any law legalising AVE and that the role of the nurse is clearly described in relevant legal acts. Future research would also be beneficial to investigate further the association between the experience of nurses working in a palliative care setting and AVE attitudes. There needs to be further debate about the legal conditions required in any future AVE bills. given the lack of support from nurses for some conditions which have been included in proposed AVE laws. Furthermore, it would be valuable to carry out surveys of the opinions of other health practitioners in order to inform legislators. These results form a baseline to examine the changes in attitudes towards AVE over time and change in the legal status of AVE.

<p><strong>Bakgrund</strong>: En utmaning för många sjuksköterskor är att bemöta patienter som efterfrågar eutanasi. När en sjuksköterska möter en patient som efterfrågar eutanasi är det till fördel om hon kan förstå varför patienten efterfrågar detta och försöka sätta sig in i patientens situation. <strong>Syfte</strong>: Syftet var att belysa eutanasi ur ett sjuksköterskeperspektiv. <strong>Metod</strong>: En allmän litteraturstudie har genomförts där 15 artiklar har använts. Artiklarna analyserades och resultatet presenterades i fem kategorier.<strong> Resultat</strong>: Sjuksköterskans upplevelser av mötet med patienten som efterfrågar eutanasi påverkades av hennes moraliska värderingar, relationer med övrig vårdpersonal och anhöriga, kunskap, juridiska begränsningar och bristen av stöd från läkare. Det framkom att sjuksköterskorna upplevde en brist på stöd från kollegorna och att kommunikationen mellan sjuksköterskorna och läkarna inte alltid var tillfredsställande. <strong>Slutsats</strong>: Som sjuksköterska är det viktigt att kunna reflektera och sätta sina egna värderingar åt sidan samt att lyssna på patienten och skapa förtroende. Att skapa relationer med samtliga inblandade i patientens vård, samt att ha en öppen kommunikation påverkar sjuksköterskans upplevelser positivt. För att få en ökad förståelse och kunskap för ämnet krävs mer undervisning under sjuksköterskeutbildningen. Debriefing efter krävande situationer skulle leda till en ökad trygghet hos sjuksköterskor.</p> / <p><strong>Background</strong>: A challenge for many registrated nurses is responding to patients who request euthanasia. When nurses meet patients who requests euthanasia, it is beneficial if they can understand why the patient made the request. <strong>Aim:</strong> The aim was to illustrate euthanasia from the nurse´s perspective. <strong>Method</strong>: The study was written as a common literature review, encompassing 15 articles. The articles were analysed and the result was presented in five categories. <strong>Result</strong>: The result indicates that nurses´experiences were influenced by her moral values. Other factors found were relationsships, knowledge and law and support. It was found that nurses experienced a lack of support by colleagues and that communication among nurses and doctors was not always satisfactory. <strong>Conclusion</strong>: As a nurse, it is important to reflect and listen to the patient to build trust. To create relationships and to have an open communication affects the nurse´s experience in a positive way. To get a better understanding and knowledge of the subject, more education is needed during nursing education. Debriefing after demanding situations would lead to a greater confidence among nurses.</p>

Eutanasifrågan är ständigt aktuell i vårddebatten. En etisk granskning utgör grund för föreliggande arbete, där etiska begrepp och principer ställts i förhållande till eutanasi. Eutanasi definieras i praxis, såsom att en läkare avsiktligt avslutar patientens liv genom administrering av en dödlig läkemedelsdos. Syftet var att belysa etiska aspekter kring eutanasi. Fjorton vetenskapliga artiklar analyserades, vilka utgjorde grunden för resultatets två teman: etiska aspekter som talar för eutanasi och etiska aspekter som talar mot eutanasi. I resultatet framhävdes självbestämmanderätten som ett argument för att eutanasi var etiskt försvarbart. Självbestämmanderätten ansågs även vara applicerbar vid frågor gällande döden. Av studien framstod autonomi vid livets slutskede som komplext, då påverkan från närstående, sjukvårdspersonal samt avsaknaden av medicinsk kunskap kunde föranleda icke-autonoma beslut. Outhärdligt lidande framkom som ett starkt argument för att eutanasi var etiskt försvarbart, men flertalet ansåg dock att den palliativa vården är tillräcklig för att lindra lidandet. Känslan av förlorad värdighet föranledde patienters önskan om eutanasi, strävan efter den goda döden framkom ideligen i artiklarna. I Sverige bör kunskap om eutanasi sökas genom att studera forskning gjord i de länder där eutanasi är legalt, vilket kan ge en fördjupad insikt kring vilka etiska aspekter som lyfts i eutanasidebatten i dessa länder. / Euthanasia is constantly current in the health-care debate. An ethical review forms the foundation for the present work, in which ethical concepts and principles set in relation to euthanasia. Euthanasia is defined in practice that a physician intentionally ends a patient's life by administering a lethal dose of medicine. The aim was to highlight the ethical aspects of euthanasia. Fourteen scientific articles were analyzed, which constitute the basis of the result's two themes: ethical aspects in favor of euthanasia and ethical aspects spoken against euthanasia. The results highlighted autonomy as an argument for euthanasia, self-determination was also considered applicable to issues regarding death. Autonomy at the end of life is complex, the influence of relatives, medical personnel and the lack of medical knowledge could lead to non-autonomous decisions. Unbearable suffering emerged as a strong argument for euthanasia, though many felt that palliative care is sufficient. The sense of loss of dignity caused desire euthanasia, the pursuit of the good death appeared constantly in the articles. In Sweden, Knowledge about euthanasia could be provided by studying research done in countries where euthanasia is legal, which can provide a deeper insight about the ethical aspects raised in the euthanasia debate in these countries.

The most commonly used method of euthanasia of laboratory rodents is exposure to carbon dioxide (CO₂), but recent studies have shown that rodents find this gas aversive. The aim of my thesis was to evaluate rat aversion to inhalant agents that could be used as humane alternatives to CO₂. The first study used approach-avoidance testing to examine rat responses to argon-induced hypoxia when argon was introduced at flow rates of 40-239% of the test cage volume per min. Rats never remained in the test cage long enough to lose consciousness when tested with argon. They consumed fewer reward items, stopped eating sooner, and left the test cage more quickly than when tested with air. Rats stopped eating and left the test cage when the oxygen (O₂) concentration had dropped to about 7.7 and 6.8%, respectively, but these O₂ concentrations are too high to cause unconsciousness. Although humans exposed to hypoxia report only subtle symptoms that include cognitive impairments and light headedness, rats are burrowing rodents and could therefore be more sensitive to these effects. I conclude that argon is not a humane alternative to CO₂. The second study used approach-avoidance testing to evaluate rat responses to different concentrations of the inhalant anaesthetics halothane and isoflurane introduced with vaporizers or from soaked cotton balls. On the first day of exposure to anaesthetics, most rats remained in the test cage until they were ataxic and showing difficulty returning to the home cage. On subsequent days of testing most rats left the test cage within seconds, but if given the option, all promptly returned and stayed until they were ataxic, indicating that the learned aversion is transient. Rats were likely sedated by the time they chose to leave, suggesting that forced exposure from the onset of aversion until loss of consciousness is less of a welfare concern than forced exposure to non-sedating agents. I suggest that the use of inhalant anaesthetics for inducing unconsciousness prior to euthanasia is a more humane method than the commonly used CO₂.

Bakgrund: En utmaning för många sjuksköterskor är att bemöta patienter som efterfrågar eutanasi. När en sjuksköterska möter en patient som efterfrågar eutanasi är det till fördel om hon kan förstå varför patienten efterfrågar detta och försöka sätta sig in i patientens situation. Syfte: Syftet var att belysa eutanasi ur ett sjuksköterskeperspektiv. Metod: En allmän litteraturstudie har genomförts där 15 artiklar har använts. Artiklarna analyserades och resultatet presenterades i fem kategorier. Resultat: Sjuksköterskans upplevelser av mötet med patienten som efterfrågar eutanasi påverkades av hennes moraliska värderingar, relationer med övrig vårdpersonal och anhöriga, kunskap, juridiska begränsningar och bristen av stöd från läkare. Det framkom att sjuksköterskorna upplevde en brist på stöd från kollegorna och att kommunikationen mellan sjuksköterskorna och läkarna inte alltid var tillfredsställande. Slutsats: Som sjuksköterska är det viktigt att kunna reflektera och sätta sina egna värderingar åt sidan samt att lyssna på patienten och skapa förtroende. Att skapa relationer med samtliga inblandade i patientens vård, samt att ha en öppen kommunikation påverkar sjuksköterskans upplevelser positivt. För att få en ökad förståelse och kunskap för ämnet krävs mer undervisning under sjuksköterskeutbildningen. Debriefing efter krävande situationer skulle leda till en ökad trygghet hos sjuksköterskor. / Background: A challenge for many registrated nurses is responding to patients who request euthanasia. When nurses meet patients who requests euthanasia, it is beneficial if they can understand why the patient made the request. Aim: The aim was to illustrate euthanasia from the nurse´s perspective. Method: The study was written as a common literature review, encompassing 15 articles. The articles were analysed and the result was presented in five categories. Result: The result indicates that nurses´experiences were influenced by her moral values. Other factors found were relationsships, knowledge and law and support. It was found that nurses experienced a lack of support by colleagues and that communication among nurses and doctors was not always satisfactory. Conclusion: As a nurse, it is important to reflect and listen to the patient to build trust. To create relationships and to have an open communication affects the nurse´s experience in a positive way. To get a better understanding and knowledge of the subject, more education is needed during nursing education. Debriefing after demanding situations would lead to a greater confidence among nurses.

The most commonly used method of euthanasia of laboratory rodents is exposure to carbon dioxide (CO₂), but recent studies have shown that rodents find this gas aversive. The aim of my thesis was to evaluate rat aversion to inhalant agents that could be used as humane alternatives to CO₂. The first study used approach-avoidance testing to examine rat responses to argon-induced hypoxia when argon was introduced at flow rates of 40-239% of the test cage volume per min. Rats never remained in the test cage long enough to lose consciousness when tested with argon. They consumed fewer reward items, stopped eating sooner, and left the test cage more quickly than when tested with air. Rats stopped eating and left the test cage when the oxygen (O₂) concentration had dropped to about 7.7 and 6.8%, respectively, but these O₂ concentrations are too high to cause unconsciousness. Although humans exposed to hypoxia report only subtle symptoms that include cognitive impairments and light headedness, rats are burrowing rodents and could therefore be more sensitive to these effects. I conclude that argon is not a humane alternative to CO₂. The second study used approach-avoidance testing to evaluate rat responses to different concentrations of the inhalant anaesthetics halothane and isoflurane introduced with vaporizers or from soaked cotton balls. On the first day of exposure to anaesthetics, most rats remained in the test cage until they were ataxic and showing difficulty returning to the home cage. On subsequent days of testing most rats left the test cage within seconds, but if given the option, all promptly returned and stayed until they were ataxic, indicating that the learned aversion is transient. Rats were likely sedated by the time they chose to leave, suggesting that forced exposure from the onset of aversion until loss of consciousness is less of a welfare concern than forced exposure to non-sedating agents. I suggest that the use of inhalant anaesthetics for inducing unconsciousness prior to euthanasia is a more humane method than the commonly used CO₂.

The current blanket prohibition of assisted death in Canada continues to be the subject of much debate. This thesis examines the shortcomings and strengths of the Belgium Law on Euthanasia of 2002 and discusses whether similar legislation could be implemented in Canada. More particularly, the thesis looks at the spirit and intent of the law, the conditions under which assisted death is permitted, and the control mechanism present in the Belgian law. The analysis of Belgium’s ten years of experience with assisted death allows us to argue that the risks inherent in assisted death regime can be controlled in a system where an exception is made for competent people in a situation of unbearable suffering. Important safeguards to prevent abuse and protect people from vulnerable groups are identified in the Belgian statute. This thesis recommends in its conclusion to regulate assisted death as an expression of compassion for suffering patients, in line with Canada’s longstanding commitment to respect for patient autonomy.

The current blanket prohibition of assisted death in Canada continues to be the subject of much debate. This thesis examines the shortcomings and strengths of the Belgium Law on Euthanasia of 2002 and discusses whether similar legislation could be implemented in Canada. More particularly, the thesis looks at the spirit and intent of the law, the conditions under which assisted death is permitted, and the control mechanism present in the Belgian law. The analysis of Belgium’s ten years of experience with assisted death allows us to argue that the risks inherent in assisted death regime can be controlled in a system where an exception is made for competent people in a situation of unbearable suffering. Important safeguards to prevent abuse and protect people from vulnerable groups are identified in the Belgian statute. This thesis recommends in its conclusion to regulate assisted death as an expression of compassion for suffering patients, in line with Canada’s longstanding commitment to respect for patient autonomy.

Thesis (Ph.D.)--Tufts University 1999. / Submitted to the Interdisciplinary Program. Adviser: Howard M. Solomon. "Doctor of Philosophy in the Interdisciplinary Program." Includes bibliographical references (leaves 454-497). Access restricted to members of the Tufts University community. Also available via the World Wide Web;