Medical end-of-life decisions in Norway
Introduction
As medicine becomes more potent and technical, an increasing number of people die as a result of a medical decision, most frequently because medical treatment is withheld or discontinued. A decision to forego medical treatment may be ethically acceptable when the treatment is judged to be of no benefit to the patient [1], [2]. Life-prolonging treatment may require additional resources, and the gap between what is technically possible on the one side, and economically feasible on the other, is probably wider than ever. Withholding and withdrawing medical treatment that can be beneficial to the individual patient, in order to save resources may be ethically problematic. The guidelines 2000 for cardiopulmonary resuscitation and emergency cardiac care [2] state that while resuscitation might not be the best use of limited medical resources, concern about cost associated with prolonged intensive care should not preclude emergency resuscitative attempts in individual patients.
The failure of medicine to relieve suffering at the end of life is an important argument for legalisation of euthanasia and physician assisted suicide (PAS). Insufficient pain control may be explained by a physician's reluctance to give adequate doses of opioids for fear of the treatment being lethal. Van der Maas shows that in the Netherlands a substantial number of patients die more or less intentionally as a consequence of the administration of opioids, without these deaths being classified as euthanasia [3]. A Swedish study found that one third of physicians working with pain relief and palliative care had given analgesics or other drugs in doses that hastened the death of some of their patients [4].
When medical treatment shortens a patient's life it may be morally justifiable through ‘the doctrine of the double effect’ [5]. A presupposition for this moral justification is the physician's intention to relieve pain but not to shorten life [6]. It may, on the other hand, be argued that adequate pain relief often saves life. The fear of killing a patient with adequate doses of pain relieving opioids may therefore be exaggerated.
Previous studies indicate that Norwegian physicians have more conservative attitudes towards such ethically controversial end-of-life decisions than physicians in other countries [7], [8], [9]. It may be postulated that this conservatism is hypocrisy, and that euthanasia is hidden under labels such as death after analgesic injections and withholding or withdrawing treatment. In a questionnaire study of 1476 Norwegian physicians (around 10% of the physician population) six percent stated that they had performed an act that hastened a patient's death [7]. The study has been criticised for the questions being too vague [10].
In the present study we have tried to use less ambiguous questions in our attempt to assess the extent that Norwegian physicians perform euthanasia, how often they experience a death following an analgesic injection, and to what extent and for what reasons medical treatment is forgone.
Section snippets
Material and method
In 1993, the Research Institute of The Norwegian Medical Association recruited a Reference Panel by inviting a random sample of 2 000 active physicians to participate. A total of 1272 agreed, and have during subsequent years received questionnaires more or less annually. 21 subjects have since dropped out, due to death or voluntary withdrawal. In January 2000 another 795 randomly selected physicians who had received their license after 1993 were invited to join the panel, of which 365 agreed.
Response rate and representativity
A total of 1318 completed and 27 blank forms were returned, a response rate of 83% (1318/1589). Table 1 compares the respondents with the population of active Norwegian physicians in April 2000. General practitioners and older physicians are slightly overrepresented, while the age group 35–44 is somewhat underrepresented.
Foregoing treatment
For 31% of the physicians the question about termination of life-prolonging treatment based on the resource situation leading to the death of a patient was ‘not applicable’. Of
Discussion
Overtreatment is a major ethical dilemma in modern medicine [7], [11]. Physicians are often accused of making death unnecessarily technical and undignified. Treatment may be continued contrary to the patient's presumed wish, against the relatives’ wish, and even contrary to the individual clinician's wish. Thus, a Norwegian study from 1993 showed that one out of three Norwegian physicians claimed that they sometimes or often had continued treatment beyond meaningfulness [7].
In the present study
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Law, ethics and clinical judgment in end-of-life decisions-How do Norwegian doctors think?
2012, ResuscitationCitation Excerpt :The reasons for this are unknown, but non-medical considerations are probably involved, such as doctors’ attitudes regarding utility and perceived responsibility for health care resources.12 Although the expenses are covered through taxation in Norway, life-saving treatment may be withheld because of resource constraints.13 The relationship between an ALS patient with decision-making capacity and the responsible doctor is demanding, since a patient's ability to exercise autonomy depends to a large extent on continuous conversations about the patient's preferences with respect to future life-prolonging treatment.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 10. The ethics of resuscitation and end-of-life decisions
2010, ResuscitationCitation Excerpt :A doctor is required only to provide treatment that is likely to benefit the patient, and is not required to provide treatment that would be futile. However, it would be wise to seek a second opinion in making this decision, for fear that the doctor's own personal values, or the question of available resources, might influence his or her opinion.66 In adult cardiac arrest various studies have addressed the impact of advance directives and DNAR orders in directing appropriate resuscitation efforts.
Culture and Attitudes Towards Euthanasia: An Integrative Review
2022, Omega (United States)Culture and end of life care: A scoping exercise in seven European countries
2020, The Ethical Challenges of Emerging Medical Technologies