Introduction
Death and dying are universal realities that are perceived differently by communities, based on their social constructs. Religion is among the social aspects that influence the attitude that people have towards death. Another aspect that affects one’s perception of death is culture, which evolves with the changes in the environment. Issues that affect the interaction of people have ethical implications because they determine the efficiency of the relationship. The principle objective of medicine and the medical profession is to provide an avenue where the medics can use their knowledge and acquired skills in alleviating the pain in patients and finally helping them enjoy the fullness of good health. To this end, the goal of medicine and healthcare is anchored on compassion for the patients and the need to alleviate pain and suffering at the quickest time possible. This researcher intends to discuss some fundamental philosophical issues that focus on understanding if ending the life of patients. In achieving the core objective of this research, the paper will delve in discussing the general purpose of medicine and healthcare. This study will also explain the ethical issues concerned with the attitude that people have towards death and dying in Saudi Arabia. Moreover, the research will examine the history of the concepts in the country from the pre-literate to the modern era, to provide an overview of cultural and religious influences on the attitudes of the citizens towards death and dying
Finally, the paper will try to justify different approaches that modern health professionals are applying to execute the task of ending the life of patients diagnosed with terminal conditions.
General Goals of Medicine and Healthcare
According to experts, the general nature of suffering of patients seems to follow a given pattern. In most instances, a patient’s nature of suffering gets worse when he or she fails to receive proper medical help and intervention in addressing the disease at hand.[1] As the situation progresses, there are high chances of the suffering becoming intense and the patient becoming more exposed to new medical risks that may end up affecting the general health situation. According to the Institute of Medicine 2001, all health professionals are trained and educated to deliver a patient-centered care approach. As such, this is expected to be the core objective of medicine and healthcare.[2] For this to be achieved, medical experts must be well versed with the nature of suffering of a patient and purpose to have a holistic approach towards ending the pain and sustaining life. Admittedly, this can only be achieved if the medical experts work as a team.
From the onset, the core objective of the medical experts should be on understanding the source of the pain in the patients, and make it their goal to use their knowledge and skills in working towards the relief of suffering.[3] The issue of considering ending a patient’s life occasioned by compassion should not be encouraged in all instances. Considering that the medical providers are human and are bound to be moved by the extreme nature of pain that a patient may be undergoing, ending the patient’s life should not be considered as a real alternative.[4]
General Nature of Suffering
Available information from medical experts indicates that many patients undergoing treatment depict a similar or a general nature of suffering. Patients who do not respond to medication immediately end up suffering while undergoing treatment.[5] As the patients continue staying at the medical facilities and undergo treatment, it has been observed that a considerable number of them demonstrate an increase in suffering. In most instances, the medics are forced to either change the medication given to address the suffering or conduct more test to ascertain the cause of the pain.[6] While the medics may manage to identify the causative agent of the pain, it has been observed in some cases that the suffering of the patient’s increases. Experts point out that in most cases, the pain experienced by a patient under treatment may not be merely physical that affects their bodies. In many cases, the suffering has its root in all the challenges that have the potential of threatening the intactness of the patient’s social and psychological entities.[7] Under such circumstances, there is little that the medicine given to the patient can achieve. When such scenarios occur, the medical experts must be quick to make an informed decision on the next possible line of intervention that will reduce and bring to an end the suffering of the patient.
Medical experts point out that it is practically difficult for most of the medics to realize this challenge from an early stage. As such, by the time the doctors are well informed on the source of suffering, the state of the patient is dire and need to help them get rid of the pain entirely through considering the ending of the life becomes an issue to consider. Most of the patients who undergo treatment believe that they will get fine sooner and get away from their suffering at the earliest possible opportunity.[8] However, when this is not realized, the patients become psychologically affected thereby increasing their level of suffering. Psychological suffering coupled with the physical pain makes the patients weaker and as such forcing the medical providers to consider ending the patient’s life out of compassion so that they can be alleviated of their pain.[9]
Core goals of Medicine and Healthcare
Considered as one of the life’s major sectors, medicine and healthcare are instrumental in the provision and sustenance of good health, which determines the livelihood of individuals.[10] From the onset, it is fair to appreciate that without the existence of medicine and healthcare, many people would be forced to undergo serious pain and suffering. To this end, it is understood that the core goals of medicine and health care are the provision and maintenance of good quality life.[11] Promotion of public health as one of the core objectives of medicine and healthcare consistently ensures that a given populace can operate and live disease free since their physical and mental health is well catered[12]. Medical experts point out that there is always an assumption that the core objective of medicine and healthcare is limited to medical facilities.[13] Unfortunately, this is not true since medics and other health care providers work beyond the medical services environment in ensuring that patients do not experience too much pain and suffering. However, there are instances in which, the medics are forced to reconsider whether their continuous medical intervention is helping their patient or is a causative agent for more pain and suffering.[14] Under such scenarios, the medics may be forced to opt to end the life of a patient to relieve the patient of the extreme pain and suffering that they are undergoing permanently.
Many organizations and human rights groups have consistently raised their concern on the matter of ending a patient’s life in the wake of extreme pain and suffering.[15] While it is true that every individual has the right to life, there are situations in which the medical experts and healthcare providers are moved by compassion to consider ending a patient’s life, thus prompting the argument of making it one of the goals of medicine.[16] Historical information indicates that the core goals of medicine and healthcare are guided by four competencies that function as the fundamentals of medical practice. These are the provision of patient-centered care, where the medics and healthcare institutions are duty-bound to identify, respect, and use everything at their disposal in alleviating the pain and suffering of the patient.[17] All these competencies constitute towards the core goals of medicine and healthcare. Unfortunately, there are many instances where advancing the core goals of medicine and healthcare becomes a challenge because of the level of pain and suffering of a patient.[18] At such cases, the medics are moved by the duty of compassion to consider ending the patient’s life to alleviate the suffering not only of the patient but also the patient’s loved ones who could be experiencing psychological trauma associated with seeing their loved one undergoing non-reversible pain.
Death and Dying History in Saudi Arabia
The perception of people about death and dying in Saudi Arabia has evolved over the decades due to the changes in the economic, social, and technological aspects. The shifts in these perceptions mainly occurred in three periods; the ancient and modern times as discussed.
Ancient Era
During the time, high death rates among the young people were a common phenomenon in the society, mainly due to poor health conditions. The simple medical practices used by the society at the time made death a familiar experience. The process of dying was perceived as painful, rapid, and unnatural act. However, other societies viewed death as a natural phenomenon that led to one’s transformation of life where the dead existed in spiritual form.[19] The living had the role of ensuring that the dead lived peacefully in the spiritual world through performing pre-death and funeral rituals.[20] A great fear of death or honor for the deceased characterized the era, depending on the attitude that the society had towards them. Communities that honored the dead conducted rituals and memorial services but those who feared death avoided their acknowledgment. The nature of rituals performed to honor the dead indicated that the society believed in life after death. Communities believed that different artifacts placed on the grave during the burial ceremonies helped the deceased in the next life.
During the time, the Saudi Arabian communities felt that death was destiny that all human beings had. The social awareness of other people’s death was among the aspects that informed the belief. Due to ineffective healthcare technology, the society accepted death as a common and natural occurrence for all human beings. Religious and cultural beliefs influenced most of the perceptions about death and dying at the time. Between the 12th and 17th centuries, the attitude of the society towards death and dying shifted from a standard view to an individual perspective. Dying was then considered an important aspect of the personal experience. Towards the end of the 17th century, the secular view of death came to be, and it became the basis for scientific knowledge.[21] The society developed a positive attitude towards death until the late 19th century when it was perceived as a fearful human experience, and it was feared. Due to the fear of death, scientists tried to develop different medical interventions in the dying process.[22] The popularity of cultural and religious beliefs about death and dying decreased as scientific knowledge advanced.
The Modern Era
The advances in pharmacology and other medical practices are among the reason why the dying process in the contemporary times is slower compared to the pre-modern era. In the modern era, dying mainly takes place at hospitals as the medical professionals try to improve the quality of life for the patients. In the past, death mostly occurred at home, under the care of their close family members and relatives.[23] Dying has been depersonalized, which explains why the dying people are separated from their families and taken to healthcare institutions instead. Although improved medical practices in the modern era prolong the dying process, the majority of people fear death in the present than in the past.[24] In some cases, the interventions used to extend one’s life are at the expense of their quality of life.[25] The modern-day medical care for the dying has a more impersonal objective, which reduces the cohesion of interpersonal relationships between the medical community and the dying persons. The lack of effective personal relationships between the dying and the healthcare professionals is among the reasons for great fear of death.[26] Although the Islamic religion gives individuals hope of life after death, Saudi Arabians and other people in the modern era still fear death.
Palliative Sedation
This section will discuss the moral aspect concerning the use of palliative sedation for patients who are terminally ill or in the final stage of dying. The practice is also called terminal sedation, and it was instituted in 1991.[27] Since its introduction for healthcare services, the program has expanded rapidly. However, there has been a comprehensive and growing debate about whether the practice is ethical or it is morally wrong because of its intended purposes. In turn, some scholars associate the approach with other life ending practices such as euthanasia and assisted suicide, but physicians have come out to clarify the meaning of terminal sedation by naming palliative sedation, as a way that can be used for intractable distress in dying.[28] Therefore, in this chapter terminal sedation is assessed with the primary focus being on the reasons that make the practice morally right for a person receiving medical treatment.
The Principle of Autonomy in Palliative Sedation
Today, individuals registered to receive medical care may experience symptoms that cannot be controlled by the best treatment methods or even palliative therapies. Hence, for the healthcare staffs to help patients with refractory symptoms, palliative sedation is taken as the only option for medication services.[29] In addition, as one of the techniques used by doctors to relieve intolerable pain through reducing patients’ consciousness, it has been argued that terminal sedation has unique ethical implications that make it a morally right in the way of treating patients with sicknesses that are beyond cure. The first moral principle that hospitals apply during the implementation of palliative sedation is the code of autonomy. Scholars suggest that the principle of autonomy is critical to the concept of terminal sedation. In this context, it means that under the guidance of autonomy, patients without the capacity of making medical decisions can shift the tasks to a substitute decision maker, as defined by the law.[30] This means that palliative sedation for people with medical need is an ethical intervention justified by the law and bioethical principles. Furthermore, it is apparent that when doctors give the relative of the opportunity patients to make the decision concerning terminal sedation, this makes the approach multidisciplinary, as it is based on specific guidelines and regulations.[31] In essence, through ethical principles, one can clearly see that palliative sedation is morally acceptable and an efficient practice that healthcare staffs can use end the suffering of patients when there is no available treatment that can stop the patients’ pain and symptoms.
The Doctrine of Double Effect
Moreover, in the cases where physicians employ terminal sedation for patients with prolonged and incurable illnesses, the doctrine of double effect is applied as an ethic measure. According to the policy of doctrine double effect, palliative sedation is acceptable, as it allow both the patients and family members to have the final say when it comes to the treatment services.[32] The statement assert that palliative sedation is meant for good intention of controlling and balancing the pain with less harmful effects that may affect the life of the patients as well as the suffering of his or her family.[33] Additionally, medical research demonstrates that doctrine of double effect is a major foundation of palliative care and it supports terminal sedation.[34] For effectiveness, the policy claims that terminal sedation work under four rules that are based on ethical and moral beliefs. According to the principle, the nature of terminal sedation must be good or morally neutral. The aspect of morally neutral makes the sedation approach ethical and a treatment concept that works under the standards of healthcare organizations. The double doctrine effect also reveals that palliative sedation must have worthy effect; the healthcare staffs must not view bad effects as a mean to show that the approach is not morally right for patients with terminal illnesses, and the method must be used to outweigh the negative impacts with positive consequences.[35] The four regulations make terminal sedation a justifiable technique that can be employed when making the decision regarding the treatment of patients in end life situations.[36] From these rules, it is evident that palliative sedation balances the effect on the patient and it considers the consequence that different treatment systems have on the patients. As such, one can see that the goal of terminal sedation is to become something perceived positively and to achieve good results even in the cases where death is unavoidable and imminent.
Assisted Suicide
Legalization of Assisted Suicide
Assisted suicide is also known as physician assisted suicide or assisted dying. In countries with high life expectancy and increasing cases of chronic diseases, debate about the eligibility of PAS continues to develop. There has been an attempt to legalize PAS in different nations, mostly in the UK and United States. In some of the European countries such as Belgium and Netherlands, PAS is permissible, despite the consequences that the practice has on the vulnerable community.[37] In the U.S., assisted suicide is allowed in three states including Oregon, Montana, and Washington.[38] This shows that the legality of assisted suicide is an area of concern for many people, especially due to the issue of ethical concept. Consequently, this section presents the moral assessment regarding physician-assisted suicide as a common way that physicians in some states are utilizing to treat people with terminal illnesses.
Moral Argument on Assisted Suicide
Assisted dying is an act of ending the life of another individual, by carrying out what is called mercy killing.[39] In states that have declared the action illegal, assisted suicide is considered as an approach that doctors conduct by violating legal and ethical boundaries.[40] One of the thing that makes physician-assisted suicide unethical practice is the aspect of respect for autonomy.[41] Just like it was mentioned in this discussion, autonomy is an essential element for the patients, and it should be protected under any circumstance. Assisted dying is impermissible and for this reason, the approach destroys the autonomy of the patients. Besides, assisted suicide does consider the aspect of patients’ freedom and positive liberty, hence making the approach unethical and practice that physicians use to deny patients the right to make the dying decision.[42] Importantly, one can argue that assisted dying fails to consider the concept of autonomy, as a central concept of bioethics. Thus, the practice is unethical, and if implemented in wider regions globally, disadvantaged groups are more likely to die differently from other people.
Euthanasia
Over the years, euthanasia has become an issue of intense debate. Advocates proclaim that euthanasia is a concept that clinicians use as a mean of speeding up the death of an individual who is under terminal medical condition.[43] As the practice reflects the work of health care professionals, it is evident to say that euthanasia makes nurses and doctors to encounter ethical issues when offering services for end life patients.
Patient Autonomy in Euthanasia Practice
According to the principle of autonomy, the value of life is a substantial element that is determined by the decision of the patients. Studies done in Netherlands shows that when healthcare professionals use euthanasia approach to treat patients with terminal illnesses, this makes them fail to acknowledge the quality of patient’s life, which is more important than the quantity.[44] At the same time, it is have been believed that euthanasia does not consider the value of human life and this is why so many people think euthanasia is wrong in all circumstances.[45] From this argument, it seems that euthanasia demeans patients’ autonomy, which makes it lower liberalism in medical ethics and the practice of treating patients. Undoubtedly, from the nursing perspective, euthanasia is a complex issue, and strict laws are needed to control the matter because patients have a right to make decisions regarding death and not being convicted under euthanasia approach.
Beneficence of Euthanasia
Scholars have argued that relieving a patient from his or her pain and suffering through euthanasia may do more good than harm. Broadly speaking, if a decision has been made to eliminate a prolonged suffering, active euthanasia can be applied, as it ends the meandering suffering that can led the death of a patient with an incurable condition.[46] Similarly, in the situation where a patient is suffering from a terminal illness, and the physician wants to exercise end life concept, one should be viewed as an agent supporting the dying decision. For the case of euthanasia, the patients are the one who holds the moral responsibility for dying because their terminal illness makes the physician end their life by injecting them with the drug that will take their life slowly.[47] Here, it is evident that despite the negative moral aspect that euthanasia has, the approach is somehow ethical because no patient is allowed to suffer unbearably and available treatment methods such euthanasia are permissible.
A closer look at this study indicates that the provision of quality healthcare and alleviation of pain is the core objective of the medical profession. However, in the course of duty, there are possibilities of instances where a patient undergoes through extreme suffering while under treatment, which cannot be reduced using medical intervention. While all health professionals focus their energies to deliver a patient-centered care, they are often moved by compassion under certain circumstances to consider ending the patient’s life who is suffering. As argued above, this has over the years raised the question on whether ending a patient’s life be a goal of medicine and healthcare using the notion of compassion. In considering the discussions and arguments put forward in this paper, there is justification for the thesis statement. However, there needs to be more research and undertakings that are necessary for the medical field in fully substantiating the thesis statement used in this research.
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Notes
[1] Cassell, Eric J. “The nature of suffering and the goals of medicine.” Loss, Grief & Care 8,no. 1-2 (1998): 129-142.
[2] Beckstrand, Renea L., Lynn Clark Callister, and Karin T. Kirchhoff. “Providing a “gooddeath”: Critical care nurses’ suggestions for improving end-of-life care.” American Journal of Critical Care 15, no. 1 (2006): 38-45.
[3] Ganzini et al., Physicians’ experiences with the Oregon death with dignity act. New England Journal of Medicine, 342 no. 8 (2000): 557-563.
[4] Jacobson, Nora. “Dignity and health: a review.” Social Science & Medicine 64, no. 2(2007): 292-302.
[5] Matiti, Milika R., and Gillian M. Trorey. “Patients’ expectations of the maintenance of their dignity.” Journal of Clinical Nursing 17, no. 20 (2008): 2709-2717.
[6] Nordenfelt, Lennart. “The varieties of dignity.” Health care analysis 12, no. 2 (2004): 69-81.
[7] Grumbach, Kevin, and Thomas Bodenheimer. “Can health care teams improve primary carepractice?.” Jama 291, no. 10 (2004): 1246-1251.
[8] Proulx, Kathryn, and Cynthia Jacelon. “Dying with dignity: the good patient versus thegood death.” American Journal of Hospice and Palliative Medicine® 21, no. 2, (2004): 116-120.
[9] Quill, Timothy. “Death and dignity: A case of individualized decisionmaking.” (1991):691-694.
[10] Klitzman, Robert. “Improving education on doctor–patient relationships andcommunication: Lessons from doctors who become patients.” Academic Medicine 81, no. 5 (2006): 447-453.
[11] Hickman et al., Use of the physician orders for life‐sustaining treatment program in Oregon Nursing facilities: Beyond resuscitation status. Journal of the American Geriatrics Society, 52, no. 9 (2004): 1424-1429.
[12] Hawkins et al. “Micromanaging death: process preferences, values, and goals in end-of-lifemedical decision making.” The Gerontologist 45, no. 1 (2005): 107-117.
[13] Hawkins et al. “Micromanaging death: process preferences, values, and goals in end-of-lifemedical decision making.” The Gerontologist 45, no. 1 (2005): 110.
[14] Costello, John. “Dying well: nurses’ experiences of ‘good and bad ’deaths inhospital.” Journal of Advanced Nursing 54, no. 5 (2006): 594-601.
[15] Costello, John. “Dying well: nurses’ experiences of ‘good and bad ’deaths inhospital.” Journal of Advanced Nursing 54, no. 5 (2006): 597.
[16] Cueto, Marcos. “The origins of primary health care and selective primary healthcare.” American Journal of Public Health 94, no. 11 (2004): 1864-1874.
[17] Cueto Marcos. “The origins of primary health care and selective primary healthcare.” American Journal of Public Health 94, no. 11 (2004): 1896.
[18] Fried et al. “Prospective study of health status preferences and changes in preferences overtime in older adults.” Archives of Internal Medicine 166, no. 8 (2006): 890-895.
[19] Ariès, Philippe. Western attitudes toward death: from the Middle Ages to the present. Vol. 3. JHU Press, 1975. 25
[20] Gawande, Atul. Being mortal: medicine and what matters in the end. Macmillan, 2014.56
[21] Dugdale, Lydia. Dying in the twenty-first century: Toward a new ethical framework for the art of dying well. MIT Press, 2015.98.
[22] Dugdale, Lydia. Dying in the twenty-first century: Toward a new ethical framework for the art of dying well. MIT Press, 2015.98
[23] Ariès, Philippe. Western attitudes toward death: from the Middle Ages to the present. Vol. 3. JHU Press, 1975., 56
[24] Dugdale, Lydia. Dying in the twenty-first century: Toward a new ethical framework for the art of dying well. MIT Press, 2015.98
[25] Gawande, Atul. Being mortal: medicine and what matters in the end. Macmillan, 2014.124
[26] Gawande, Atul. Being mortal: medicine and what matters in the end. Macmillan, 2014.124
[27] Henk ten Have, M. D., Jos VM Welie, and J. D. MMedS. “Palliative Sedation Versus Euthanasia: An Ethical Assessment.” Journal of Pain and Symptom Management 47, no. 1 (2014): 123.
[28] Henk ten Have, M. D., Jos VM Welie, and J. D. MMedS. “Palliative Sedation Versus Euthanasia: An Ethical Assessment.” Journal of Pain and Symptom Management 47, no. 1 (2014): 124.
[29] Maltoni, M., C. Pittureri, E. Scarpi, L. Piccinini, F. Martini, P. Turci, L. Montanari, O. Nanni, and D. Amadori. “Palliative sedation therapy does not hasten death: results from a prospective multicenter study.” Annals of Oncology 20, no. 7 (2009): 1164.
[30] Sinclair, Christian T., and Richard C. Stephenson. “Palliative sedation: assessment, management, and ethics.” Hospital Physician 42, no. 3 (2006): 36.
[31] Khader, M. M., and M. T. Mrayyan. “The Use of Palliative Sedation for Terminally Ill Patients: Review of the Literature and an Argumentative Essay.” Journal Palliative Care Medicine 5, no. 226 (2015): 3
[32] Khader, M. M., and M. T. Mrayyan. “The Use of Palliative Sedation for Terminally Ill Patients: Review of the Literature and an Argumentative Essay.” Journal Palliative Care Medicine 5, no. 226 (2015): 3
[33] Khader, M. M., and M. T. Mrayyan. “The Use of Palliative Sedation for Terminally Ill Patients: Review of the Literature and an Argumentative Essay.” Journal Palliative Care Medicine 5, no. 226 (2015): 4
[34] Sinclair, Christian T., and Richard C. Stephenson. “Palliative sedation: assessment, management, and ethics.” Hospital Physician 42, no. 3 (2006): 36
[35] Sinclair, Christian T., and Richard C. Stephenson. “Palliative sedation: assessment, management, and ethics.” Hospital Physician 42, no. 3 (2006): 37
[36] Olsen, Molly L., Keith M. Swetz, and Paul S. Mueller. “Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments.” In Mayo Clinic Proceedings 85, no. 10, (2010): 949-954.
[37] Steck, Nicole, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahlen, and Matthias Egger. “Suicide assisted by right-to-die associations: a population based cohort study.” International journal of epidemiology 43, no. 2 (2014): 614
[38] Steck, Nicole, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahlen, and Matthias Egger. “Suicide assisted by right-to-die associations: a population based cohort study.” International journal of epidemiology 43, no. 2 (2014): 614
[39] Grewal, Bhajneek, Jennifer Harrison, and David Jeffrey. “Licensed to kill–the impact of legalising euthanasia and physician assisted suicide on the training of UK medical students.” Scottish Universities Medical Journal 1, no. 1 (2012): 6
[40] Koutoukidis, G., Lawrence, K., & Tabbner, A. R. (2008). Tabbner’s nursing care: Theory and practice. Chatswood, N.S.W: Elsevier Australia. 177
[41] Sjöstrand, Manne, Gert Helgesson, Stefan Eriksson, and Niklas Juth. “Autonomy-based arguments against physician-assisted suicide and euthanasia: a critique.” Medicine, Health Care and Philosophy 16, no. 2 (2013): 226
[42] Sjöstrand, Manne, Gert Helgesson, Stefan Eriksson, and Niklas Juth. “Autonomy-based arguments against physician-assisted suicide and euthanasia: a critique.” Medicine, Health Care and Philosophy 16, no. 2 (2013): 227
[43] Keown, Damien. “End of life: the Buddhist view.” The Lancet 366, no. 9489 (2005): 952.
[44] Widdershoven, Guy AM. “Beyond autonomy and beneficence. The moral basis of euthanasia in The Netherlands.” Euthanasia and palliative care in the low countries (2005): 4
[45] Webb, Patricia. Ethical Issues in Palliative Care. Abingdon: Radcliffe, 2005.116
[46] Nathan, Rae. “Is Euthanasia Morally Permissible? Why or Why Not?” Sound Decisions: An Undergraduate Bioethics Journal 1, no. 1 (2015): 4
[47] Nathan, Rae. “Is Euthanasia Morally Permissible? Why or Why Not?” Sound Decisions: An Undergraduate Bioethics Journal 1, no. 1 (2015):
