Euthanasia: A of on Healthcare Industry and Public Opinion - Literature review Example

Euthanasia: A Review of Literature on Healthcare Industry and Public Opinion 5 February Introduction The United Kingdom promotes a healthcare policy that aims to expand choices and access to quality end-of-life care (Department of Health, 2008). The UK Government published its first “End of Life Care Strategy” report, which aims to cater to adults who are nearing their death. Improving end-of-life care is central to healthcare providers, and this goal, among other factors, affects how they perceive euthanasia. The practice of euthanasia-like procedures is not that rare in UK settings. Withdrawal of intensive care treatments, in the absence of patient recovery, is becoming more widespread in the United Kingdom (UK), United States of America (USA), and other parts of Europe. In England, however, euthanasia and assisted suicide are illegal and punishable by law (National Health Service, 2012). The National Health Service (NHS) (2012) reports that depending on environmental factors, the law can see euthanasia as either manslaughter or murder and can be punished with a maximum penalty of life imprisonment. Assisted suicide is prohibited under the rules of the Suicide Act (1961) and can be punished by up to 14 years of imprisonment (NHS, 2012). Trying to commit suicide is not seen as criminal act (NHS, 2012). Euthanasia in the UK is prohibited, but its implementation is unclear, nevertheless. For instance, doctors in the UK are not authorised to give treatment that leads to death, but they can withhold artificial nutrition and hydration (called as life‐prolonging treatments by the British Medical Association), if they think that it serves the ‘best interests’ of their patients (Chapple et al., 2006). When consensus is not attained, any decision for this action must be court-approved, but the meaning of “best interests” can be divisive (Chapple et al., 2006). Providing food and drink to the sick has been traditionally viewed as part of ‘compassionate care,’ and stopping patients from getting food and water can be argued as involuntary euthanasia or murder (Chapple et al., 2006). UK law is seriously inconsistent because it allows starvation upon request, but criminalises euthanasia. This report aims to understand the views of healthcare providers and the public on euthanasia. It reviews existing qualitative and quantitative research, which includes surveys, interviews, and phenomenological studies. The main emphasis is on the UK setting, but other studies were included where cross-cultural examines are made that included the UK. Qualitative Studies Face-To-Face Interviews Nurses. In ‘Negotiated Dying: A Grounded Theory of How Nurses Shape Withdrawal of Treatment in Hospital Critical Care Units,’ Long-Sutehall et al. (2011) explore the tensions involved between providing care for terminally-ill patients and their families. Their main objective is to demonstrate how varied dying trajectories shape decision-making that lead to withdrawal of treatment processes, and the role of nurses in the decisions for withdrawal of treatment. Dying trajectories are ‘perceived courses of dying rather than the actual courses’ [of dying] (Glaser and Strauss, 1968: 6 cited in Long-Sutehall et al., 2011: 1469). Critical care concerns hospital areas that support those who are seriously ill, such as general intensive care (GICU), cardiac (CICU), neurological (NICU) and renal high care (RHC) units. The most common dying trajectories in CICU and GICU were either, 1) an acute admission subsequent to a critical injury [illness] or planned surgical operation after dangerous deterioration with slight or no reaction to interventions over a moderately short time line [hours], or 2) a prolonged process of “one step forward and one step back, with pauses when the patient is not moving in either direction [days or weeks]” (Long-Sutehall et al., 2011: 1469). Long-Sutehall et al. (2011) conducted a twelve-month study from September 2008 to September 2009, using qualitative methods of enquiry and modified grounded theory method. The participants were nurses from four clinical critical care units in the south of England, and who were frequently involved in withdrawal of treatment of their patients. Sampling strategy is convenient sampling. Thirteen nurses participated in the study, where the interview took place at the time and place convenient to them. Interviews were done through clinical vignettes, which were made through the help of the author’s professional colleagues. They chose this technique to help participants talk about sensitive issues from a “non-personal, and potentially less threatening perspective” (Long-Sutehall et al., 2011: 1468). Findings showed that “contested boundaries” affected these trajectories that were related to delays in decision-making regarding the process of withdrawing treatment. In CICU, GICU and NICU, nurses evaluated patients’ wishes by speaking with the patients’ family, and considering their own outlook of how death ‘should’ press forward (Long-Sutehall et al., 2011: 1472). Nurses had an essential role in checking and enhancing the families understanding of what would come about during treatment withdrawal and in expressing the actual, as opposite to, the “perceived dying trajectory” (Long-Sutehall et al., 2011: 1472). Long-Sutehall et al. (2011) talked about potential disagreements between doctors and nurses, when doctors are accountable for diagnosis and prognosis and they are legally responsible for producing withdrawal of treatment decisions, and so their clinical view may concentrate on ‘extending life,’ while nurses, as they operationalise processes, may be more open to ‘allowing life to end’ (1473). These different views can lead to contested boundaries because of unclear roles, goals, and conceptions of death. Physicians. Physicians have different conceptions of euthanasia and whether it must be approved in UK law. Pasman et al. (2009) explore the idea of ‘unbearable suffering’ for euthanasia settings in the ‘Concept of Unbearable Suffering in Context of Ungranted Requests for Euthanasia: Qualitative Interviews with Patients and Physicians.” Supporters of euthanasia assert that experiencing unbearable suffering can justify its request. Pasman et al. (2009) conducted in-depth interviews. Sampling included ten patients who unequivocally requested euthanasia, but their requests were either denied by their doctors or were waiting for approval, and eight physicians. Findings showed the differences on what constitutes unbearable pain between patients and doctors. Patients consider psychosocial conditions as part of their unbearable pain, while doctors focus more on its physical dimensions. Surprisingly, patients still wish to die even without feeling ‘unbearable pain.’ Pasman et al. (2009) conclude that this gap between what patients and doctors consider as unbearable pain can help explain their differing attitudes to euthanasia. Seymour, Janssens and Broeckaert (2007) examine clinicians’ (both nurses and doctors) and academic researchers’ interpretations and experiences of palliative sedation for managing suffering at the end of life, and their opinions about its clinical, ethical and social implications. Their sampling included eleven doctors, fourteen nurses and ten researchers, who participated in informal interviews and work at palliative care settings and research units in the UK, Belgium and the Netherlands. Seymour et al. (2007) also collected related reports and papers from the academic, clinical and popular press. Palliative sedation has been suggested as an alternative path to euthanasia. Findings were divided into the following themes: ...understanding and responding to suffering; the relationship between palliative sedation and euthanasia; palliative sedation and artificial hydration; and risks and uncertainties in the clinician-patient/family relationship. (Seymour et al., 2007: 1679). The UK clinicians believed that as palliative care specialists, they faced the outcomes of the inconsistent and potentially opposing cultural meanings linked with the methods used to alleviate suffering, where while it is seen that it is a main duty of medicine to reduce suffering, the essential actions necessary can be interpreted as efforts to speed up death (Seymour et al., 2007: 1683). Respondents from the UK generally see palliative sedation from a standpoint that the discourse of palliative care strongly supported and this can explain the opposition to euthanasia. They can see palliative sedation as a suitable reaction to suffering and as part of the creative solutions to symptom control in terminal illness (Seymour et al., 2007: 1687). They feel, nevertheless, that palliative solutions are last resorts for rare circumstances and cannot even be compared to euthanasia. Patients. The ideas and opinions of those terminally ill and may request euthanasia are significant since they are the ones who will be accessing it when legalized. In ‘What People close To Death Say about Euthanasia and Assisted Suicide: A Qualitative Study,’ Chapple et al. (2006) study the actual lives of people with a ‘terminal illness,’ concentrating on their views toward euthanasia and assisted suicide. After obtaining the authorisation of the ethics committee, the authors recruited people living in the UK to partake in the examination of the experience of ’living with a terminal illness.’ Sampling included 41 people who said that they had a terminal illness. Findings revealed a range of viewpoints on euthanasia, especially when involuntary euthanasia is concerned. Some of them wanted the option of ending their lives. Others mostly had numerous reasons for changing euthanasia law, “including the right to choose when to end their own life, pain, anticipated pain, cognitive impairment, fear of indignity, fear of loss of control and concern that they may be a physical or financial burden on others” (Chapple et al., 2006). Others were saddened that they would have to die alone if they committed suicide (Chapple et al., 2006). A small number opposed changing the law because of their alarm for involuntary euthanasia, while several were hesitant about a change in the law that would permit voluntary euthanasia because they were concerned of misuse or abuse (Chapple et al., 2006). The right to autonomy over one’s life can be a significant driver of requesting for euthanasia among patients. In the study conducted by Pasman et al. (2009), some patients already wish to die because of their own idea of unbearable pain or even without it. These patients believe in their right to euthanasia, though their doctors tend to disagree because of the absence of physical signs of unbearable pain. Personal Expressions Physicians. Other physicians assert that euthanasia is a slippery slope that must be avoided. In ‘Legalisation of Euthanasia and Assisted Suicide: A Professionals View,’ Gannon and Garland (2008) respond to an IJPN article, ‘Health Professionals Opposition to Euthanasia and Assisted Suicide: A Personal View’ (Vocht and Nyatanga, 2007). Vocht and Nyatanga explored the professional debate on euthanasia/physician-assisted suicide (PAS). Gannon and Garland (2008) oppose Vocht and Nyatanga’s allegation of “misguided paternalism,” with the inaccurate proposition that health care professionals (HCPs), who do not approve of the legalisation of euthanasia/PAS, aimed to refute patient choice. They argue that killing patients cannot be aligned with the concept and practice of palliative care, which seeks to assist patients in living a quality end-of-life stage (Gannon and Garland, 2008: 127). Palliative care, however, does not prevent patients from using alternative options that can allow them to precipitately end their life. For instance, patients can elect to stop life-sustaining treatments because existing law previously completely protects the patients right to decline any or all treatment, for any or no reason (Gannon and Garland, 2008: 127). Furthermore, UK statute offers advance decisions, so that patients refusal of treatment can be applied, including instances when the capacity to approve this is lost (Gannon and Garland, 2008: 128). Gannon and Garland (2008) believe that a Euthanasia bill will result to risks to HCPs, patients, and their families. They emphasise the subsequent load on defenceless patients of needing to think about euthanasia/PAS, instigating the need to consider a duty to die rather than a right to die (Gannon and Garland, 2008: 129). This bill, furthermore, can redirect staff and concentration away from the majority of people who do not want euthanasia (Gannon and Garland, 2008: 129). Furthermore, the Bill would unavoidably destabilize the professional trust which is the heart of the HCP-patient therapeutic relationship (Gannon and Garland, 2008: 129). Legalisation of euthanasia would be destructive in its capability to stimulate misunderstandings and redirect attention from the certainties of present laws (Gannon and Garland, 2008: 129). Gannon and Garland (2008) conclude that euthanasia is not required to be legalised: ‘Euthanasia/PAS decisions are too complex to be legalised safely’ (129). They call for further debate in the healthcare industry, so that the implications and challenges of euthanasia can be properly examined. Grogan et al. (2009) agree with Gannon and Garland (2008). In ‘End-of-Life Decisions in the United Kingdom Involving Medical Practitioners and Legalisation of Euthanasia or Physician-Assisted Suicide: Survey of Doctors’ Attitudes,’ Grogan et al. (2009) speak for the Association of Palliative Medicine, an organisation of more than 1000 palliative doctors in hospitals and hospices all over United Kingdom and Ireland. They assert that majority of their members oppose any changes in existing law on assisted dying. They stress that as doctors who work closely with the dying, their opinions have great value. Grogan et al. (2009) criticize healthcare professionals outside palliative care who use the concept of double effect to assist suicide. Double effects means that sedatives are used to end life, which Grogan et al. (2009) note have no substantial scientific support. Like Gannon and Garland (2008), they are concerned that the legalisation of euthanasia can result to duty to die instead of a right to die. UK Medical Students With the ongoing debate on euthanasia, its effect on existing medical students cannot be overlooked because they may one day face a world where euthanasia is allowed. Grewal, Harrison and Jeffrey (2012) express the viewpoints of medical students in “Licensed to Kill – The Impact of Legalising Euthanasia and Physician Assisted Suicide on the Training of UK Medical Students.” They presented the concepts that are related to euthanasia, such as role contradiction, trust, value of life, dignity of choice, and practicalities. They argued that euthanasia is against their fundamental goals as medical students, where one day, they will save and extend lives, not end it. They say: If the above legislation had passed before I applied to medical school, and I had known that my future would include euthanizing patients this would have made me seriously question the fundamental principles of medicine. I wonder if, as a consequence of this legislation, Medicine would attract a different group of applicants; those who do not say at their interview, “I want to help people” but instead say, “I want to help people to die.” (Grewal, Harrison and Jeffrey, 2012: 12). These sentiments demonstrate that these medical students are averse to the principles of euthanasia that violate their core ideas of what medical practice is all about. They do not support it because it is not aligned with their Hippocratic Oath. Phenomenology The boundaries of euthanasia are contested grounds. Leget (2006) explored this thesis further in ‘Boundaries, Borders, and And Limits. A Phenomenological Reflection on Ethics and Euthanasia.’ He reflected on the way that boundaries affect viewpoints on euthanasia. He argues that boundaries have a large role in perceiving and reacting to euthanasia. He describes euthanasia as ‘direct and intentional killing at the patient’s explicit and long term request’ (256). He says that ‘limit’ is a more appropriate term from the patient’s perspective, while it is a ‘border’ from a helicopter perspective. He stresses that seeing euthanasia this way reveals that people who oppose or support it are two sides of the same coin. Leget (2006) concludes that the phenomenological approach allows contending parties to map out diverse interests and problems. Both interests and ambiguities are critical in having a balanced approach to understanding euthanasia discourse. Quantitative Research Survey of Healthcare Professionals Healthcare professionals, based on studies in this paper, have different perceptions of euthanasia, which affect their approval of or refusal for it. Breen et al. (2010) note in Good Medical Practice: Professionalism, Ethics and Law, that according to a postal survey, 3733 doctors in the UK, or 2/3 of the responding rate, were opposed to the legalisation of euthanasia (341). Randall and Downie (2010) show similar findings in End of Life Choices: Consensus and Controversy. They note recent 2006 surveys of the UK Royal College of Physicians and the BMA, where majority of doctors from palliative medicine, geriatrics, and oncology are against euthanasia’s legalisation. In ‘U.K. Physicians Attitudes toward Active Voluntary Euthanasia and Physician-Assisted Suicide,’ Dickinson et al. (2002) compared the opinions of geriatric medicine physicians and intensive care physicians in the UK on the issues of active voluntary euthanasia (AVE) and physician-assisted suicide (PAS) revealed. They used the mailing lists and authorization of two U.K. medical specialty groups with high chances of having seriously ill patients: the British Geriatrics Society and the Intensive Care Society, with headquarters in London. Authors got a return rate of 45% from the geriatricians (n = 333) and a 37% return rate from the intensive care doctors (n = 300). Findings showed that these medical specialists differ in their support for AVE and PAS, where the intensive care physicians are more supportive of AVE and PAS and more willing to take part than are the geriatric medicine doctors (but only few showed readiness to participate). Dickinson et al. (2002) explain potential reasons of these differences. The elderly, they stress, may be more ready to die than young patients, but geriatricians tend to know their patients more than intensive care physicians. As a result, geriatricians have an ‘established relationship’ with patients that make them less likely to agree with requests of withdrawal of treatment (Dickinson et al., 2002: 486). Dickinson et al. (2002) stress that even when numerous physicians oppose the legalisation of euthanasia, it should not be seen as “automatically ...equated with opposition to euthanasia and PAS,” where “Such a response could be interpreted as a preference for dealing with these matters on a case-by-case basis, within the confines of the patient-family-physician relationship, and away from the arena of public policy, regulation, and legislation” (487). They emphasise the possibility that while public opinion is turning toward a greater support for euthanasia and PAS, “physicians may be making the tactical decision that they can deal with this more effectively without, rather than with, a settled public policy” (Dickinson et al., 2002: 487). Some of the limitations of the study are low response rate and the impact of actually having euthanasia on responses. Nonetheless, this study presents surprising results, where geriatric medicine doctors are less likely support AVE and PAS, when their patients tend to near the end of their lives and may suffer complicated illnesses. Some nurses have actively participated in the discussions and execution of ending life in critical circumstances. In EfCCNa Survey: European Intensive Care Nurses Attitudes and Beliefs towards End-Of-Life Care,’ Latour, Fulbrook, and Albarran (2009) examine the attitudes and perspectives of ICU nurses towards End-of-life or EOL care. EOL care was “defined as the care and supportive services to a patient and family after the decision is made to withdraw or withhold a treatment” (Latour et al., 2009: 118). The convenience sample was taken from 419 intensive care nurse participants, who participated in the second European critical care nursing congress of EfCCNa in November 2005. 162 responses were used. Findings showed that although a 50.6% of nurses did not concur that withholding and withdrawing life-supporting treatment were morally the same, around 45.7% said that they were. In decisions to take out or withhold therapy, 65% would reduce the flow of inspired oxygen, 98.8% give continuous pain relief and 91.3% support open visiting. These findings indicate that nurses play an active role in shaping EOL decisions, where they make suggestions to physicians too, based on what families express to them. Nurses are showing more favour for legalisation of euthanasia because they deal with patients and their families more than physicians. Sumner (2011), in Assisted Death: A Study in Ethics And Law, cites the 2003 survey of Nursing Times on UK nurses, where two-thirds of the respondents state that euthanasia should be allowed and one-third think that nurses should be allowed to conduct it (195). Cuttini et al. (2004) show that nurses tend to support euthanasia more, although this depends in many factors in ‘Should Euthanasia Be Legal? An International Survey of Neonatal Intensive Care Units Staff.’ Their sample included 142 HCPs from neonatal intensive care units, who were “recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom)” (Cuttini et al., 2004: F19). A total of 1391 doctors and 3410 nurses finished an anonymous questionnaire. The staff generally supported the move to legalise active euthanasia, particularly in Netherlands, France, and to a lesser degree Lithuania. Cuttini et al. (2004) observe that being male, having regular participation in research, less than six years professional experience, and having ever contributed in a decision of active euthanasia were positively linked with an opinion favouring reduction of legal constraints. On the opposite, having had children, religiousness, and believing in the unqualified value of human life resulted to a negative association (Cuttini et al., 2004: F19). Nurses were slightly more likely to regard active euthanasia acceptable in particular circumstances and to believe that the law should be changed to enable more now than before (Cuttini et al., 2004: F19). Survey of Public Opinion The public is becoming more supportive of euthanasia in the U.K. Johnstone (2009) cited a 2002 public poll which showed that 81% of those surveyed supported euthanasia for people with unbearable suffering because of terminal illness (257). The House of Lord asked the Committee on the Assisted Dying for the Terminally Ill Bill (2005) to conduct a study on euthanasia, which resulted to the report, Assisted Dying for the Terminally Ill (ADTI) Bill - First Report. Findings showed that the public wants more doctors to permit assisted euthanasia: ‘BSA surveys in 1984, 1989 and 1994 showed an increasing majority (75% rising to 82%) in favour of doctors being allowed to end the life of a patient suffering from ‘a painful incurable disease’’ (Committee, 2005: par. 218). Furthermore, there is growing support for people to access euthanasia options: NOP polls commissioned by the VES in 1976, 1985, 1989 and 1993 showed a similar pattern of support for the proposition that adults should be allowed ‘to receive medical help to an immediate peaceful death if they suffer from an incurable physical illness that is intolerable to them.’ (Committee, 2005: par. 218). These people want access to a peaceful form of death, when incurable illnesses are present. At the same time, polls showed that many people believe that people with terminal illnesses must be given the option for euthanasia Similar NOP polls commissioned by the VES in 2002 and 2004 showed over 80% support for the proposition that ‘a person who is suffering unbearably from a terminal illness should be allowed by law to receive medical help to die, if that is what they want.’ (Committee, 2005: par. 218). These polls indicate the pulse of the masses, where they are trying to empathize with patients who have reasons to want to die, and so they must have the right to die in their own set of terms. The reality is that euthanasia per se is illegal, and yet polls showed helping others in euthanasia in certain circumstances. The Committee shows: A 2004 VES-sponsored survey suggested that 47% of the population might be prepared to break the current law to assist someone else to take his or her own life in the case of terminal illness and unbearable suffering. (Committee, 2005: par. 225). The condition of terminal illness and unbearable suffering tend to make people forget the laws and focus on human compassion. A deeper understanding of public opinion is important because this paper is interested in a cross-sectional analysis of euthanasia supporters and critics. Who are the people against and in support of euthanasia and why? Verbakel and Jaspers (2010) study the underlying reasons for supporting euthanasia through examining differences among individuals and countries through four arguments from the euthanasia debate in ‘A comparative study on permissiveness toward euthanasia.’ Verbakel and Jaspers (2010) hypothesize that national context affects euthanasia attitudes, specifically religious climate, health systems, general attitude toward autonomy, and suffering at national levels. They conducted multilevel analysis on data collected from thirty-three countries. Data came from the European Values Study 1999/2000 and the World Values Survey 2000, where response rates were around 60% on the average (Verbakel and Jaspers, 2010: 117). They added country-specific characteristics to their analysis. The religion-based argument asserts that religious people oppose euthanasia on religious grounds, where only God can decide who lives and dies (Verbakel and Jaspers, 2010: 113). The slippery slope argument is concerned that “voluntary euthanasia will lead to involuntary euthanasia practices” (Verbakel and Jaspers, 2010: 113). The autonomy argument says that the right of self-determination is a basic element of the concept of personal autonomy. People who strongly support the value of autonomy tend to support euthanasia too (Verbakel and Jaspers, 2010: 113). Finally, death with dignity argument stresses that people who have individually seen physical suffering are more tolerant of euthanasia practices (Verbakel and Jaspers, 2010: 113). Findings supported hypotheses based on religiosity, slippery slope, and autonomy, while there was weak support for death-with-dignity. Authors also learned that national context reduces the gap between opponents and proponents of euthanasia (Verbakel and Jaspers, 2010: 113). Polls on people with disabilities have mixed results. Assisted Dying for the Terminally Ill Bill notes that a 2003 poll for the Disability Rights Commission indicated, though with a small sample, that disabled people were afraid that the bill will result to abuse of euthanasia on their group (Committee, 2005: par. 221). On the opposite, a 2004 YouGov survey stress that disabled people showed support for the ADTI Bill as forcefully as non-disabled people (Committee, 2005: par. 221). . The attitudes of disabled people appeared to be more mixed. Further studies with large sampling and randomized sampling approaches are needed to provide more robust data on the opinions of people with disabilities. People with HIV tend to support euthanasia, though at particular circumstances. Andraghetti et al. (2001) study the opinions of people with HIV toward euthanasia in ‘Euthanasia: From the Perspective of HIV Infected Persons in Europe.’ They conducted a cross-sectional survey of persons with HIV and who attended HIV/AIDS treatment centres or HIV support organizations in eleven European Union Member States. Sampling included 2751 anonymous patient self-administered questionnaires. One thousand three hundred and seventy-one people with HIV infection submitted answers to the questionnaire, where 1341 (98%) answered questions concerning euthanasia. Findings showed that seventy-eight percent of respondents wanted to legalise euthanasia in case of severe physical suffering, 47% if there was relentless psychological suffering and 24% on the basis of patients request. Their approved practices were mitigation of pain with double effect (81%), medical euthanasia (62%) and physician assisted suicide (45%) (Andraghetti et al., 2001). Fifty percent approve euthanasia for themselves if no other treatments were accessible (Andraghetti et al., 2001). Social factors such as educational level and employment seemed to have influenced the role in forming attitudes towards legalisation, and personal interest in, euthanasia than indicators that are connected with the disease status. These people are not afraid of the slippery slope or abuse and tend to believe that they should access euthanasia if the need for it arises. Conclusions Studies showed mixed results on the opinions regarding euthanasia, although a slight increase of support among palliative medicine and intensive care practitioners is seen, as well as for nurses. Nurses may be more favourable of the legalisation of euthanasia because of their more direct and prolonged contact with patients and their families. Public support, on the opposite, is increasing, especially when they consider the unbearable suffering of the terminally ill. Patients with terminal illness express the support for euthanasia too, as an option, whether they are in unbearable pain or not. Individual and national factors temper the public support for euthanasia, where religiousness and concern of involuntary euthanasia are negatively related to support for it, while beliefs for autonomy and right to choices increase support. Hence, this study shows that euthanasia continue to be a contested issues, one where practitioners, politicians, and patients will continue to discuss and negotiate. References Andraghetti, R., Foran, S., Colebunders, R., Tomlinson, D., Vyras, P., Borleffs, C.J., Fleerackers, Y., Schrooten, W. and Borchert, M. (2001) ‘Euthanasia: from the perspective of HIV infected persons in Europe,’ HIV Medicine, vol. 2, no. 1, pp.3-11. Breen, K.J., Cordner, S.M., Thomson, C.J.H. and Plueckhahn, V.D. (2010) Good medical practice: professionalism, ethics and law, Cambridge: Cambridge University Press. 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