A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries.

OBJECTIVES: To analyse legislation and medical professional positions concerning the doctor's role in assisted dying in western Europe, and to discuss their implications for doctors. METHOD: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised (Belgium, The Netherlands), or openly practiced (Switzerland), or where it is illegal (Germany, Norway, UK). RESULTS: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide (but not euthanasia) is not illegal in either Germany or Switzerland, but a doctor's participation in Germany would violate the code of professional medical conduct and might contravene of a doctor's legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not. Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This "neutral" stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a "medical end-of-life decision" since the 1970s. CONCLUSION: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions.

[Information for family members with an increased risk for a genetic disease]. / Aufklärung von Familienangehörigen mit erhöhtem Risiko für eine genetische Krankheitsdisposition.

After a genetic diagnosis a physician might deem it important to inform family members of his counselee who might have an increased risk of having a certain genetic predisposition. Against this background this contribution analyzes the following ethical questions: 1. To what extent is the physician ethically obligated to see to it that the family members are being informed? 2. Are there circumstances under which the physician is ethically allowed to violate his obligation of confidentiality? 3. Is it ethically allowed to refuse a genetic test when the counselee does not agree with informing family members even if this might clearly be in their interest? 4. Is it ethically allowed to inform family members about an increased risk of a genetic predisposition in the family without their explicit request?

[No arguments to support an age limit for men entering an in vitro fertilisation or intracytoplasmic sperm injection programme]. / Geen onderbouwing voor maximale leeftijdsgrens voor mannen bij in-vitrofertilisatie of intracytoplasmatische sperma-injectie.

OBJECTIVE: To identify medical and psychosocial risks that could arise from allowing older men to father children through in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). DESIGN: Literature review. METHOD: The databases Medline, Current Contents weekly, Current Contents archives, and PsycINFO were searched over the period 1970--June 2004 for articles with data on age limits for men entering IVF/ICSI programmes. The following inclusion criteria were used: availability in the Netherlands and written in English or Dutch. RESULTS: Although sperm quality decreases with age, men remain fertile up to an advanced age. The risks of having children with autosomal dominant disorders or chromosomal defects increase slightly, but the individual chance is extremely small. Studies on the psychological development of children with fathers aged > 50 years are lacking. Extrapolation from other studies indicates that growing up with an older father has no negative influence on child development. Although older fathers have a greater chance of dying sooner, the absence of the father does not contribute significantly to psychological problems in offspring later in life. CONCLUSION: There are no medical or psychosocial arguments to support an age limit for men entering an IVF/ICSI programme.

[Cosmetic dentistry. An ethical reflection on the boundaries of embellishment]. / Esthetica in de tandheelkunde. Een morele reflectie op de grenzen van de verfraaiing.

From a technical point of view the possibilities of aesthetics in medicine and dentistry are unlimited. This makes the call for moral boundaries a number one topic. It is especially this 'question of boundaries' with regard to the realisation of embellishments, which is considered problematic: who determines the moral boundaries of dental intervention for embellishment purposes and where do those moral boundaries of embellishment lie? Considering the increasing possibilities it is not advisable to just leave this to the individual dentist, let alone to the patient. Te vision of the profession is needed, so that the individual dentist feels supported.

[Voluntary euthanasia in the Netherlands]. / Freiwillige aktive Sterbehilfe in den Niederlanden - Von der Duldung zur gesetzlichen Regelung -

On 10 April last, the Dutch Senat accepted a new bill concerning voluntary active euthanasia and physician assisted suicide. This bill legally embodies a ground for exemption from punishment for physicians who conducted voluntary active euthanasia or physician assisted suicide and who complied with certain requirements. Hence, the old policy of tolerance has been transformed into a legal system of acceptance of certain forms of voluntary active euthanasia and physician assisted suicide. This contribution describes these legal changes as the final stage of a process of integration of voluntary active euthanasia and physician assisted suicide in Dutch society. In this way, it endeavours to contribute to a constructive debate.

Regulating moral dissent in an open society: The Dutch experience with pragmatic tolerance.

In pluralistic modern societies, moral dissent will, to an increasing extent, be an inescapable fact in our lives. Moral dissent, however, involves various serious dangers: escalation of conflicts, the use of violence, flourishing of radical extremism and even civil war. There are basically two ways in which these threats can be addressed: coercive enforcement of consensus or tolerance. First, we could try to eliminate moral dissent by using more dictatorial forms of consensus formation, like propaganda, indoctrination and terror. This, however, would endanger or even destroy the open society. Therefore, from a moral point of view, tolerance appears to be the more desirable antidote to the unwanted effects of moral dissent. This paper aims to contribute to the discussions about the regulation of moral dissent and the formation of moral consensus by analyzing one of the most important and idiosyncratic elements of the Dutch way of handling these issues: pragmatic tolerance. First, some general thoughts are developed about moral consensus, moral dissent and tolerance as a means of regulating dissent. In addition, the characteristic Dutch policy of pragmatic tolerance is described. Finally, some of the pros and cons of pragmatic tolerance are analyzed from an ethical perspective.

New developments in Dutch legislation concerning euthanasia and physician-assisted suicide.

Dutch euthanasia and physician-assisted suicide stand on the eve of important legal changes. In the summer of 1999, a new government bill concerning euthanasia and physician-assisted suicide was sent to Parliament for discussion. This bill legally embodies a ground for exemption from punishment for physicians who conduct euthanasia or physician-assisted suicide and comply with certain requirements. On November 28, 2000, the Dutch parliament approved an adapted version of this bill. Since the approval by the Dutch Senate can be regarded as a formality, it is expected that the bill will come into force in the course of this year (2001). In this paper we discuss these new developments.

Issues in Dutch palliative care: readjusting a distorted image.

This issue presents a review of several issues in Dutch palliative care, paying attention to readjusting a distorted image due to the euthanasia practice in the Netherlands. A few articles stress the evolution of palliative care (especially in the UK and the Netherlands), developed palliative care services in the Netherlands, and new developments in the Netherlands concerning the prevention of euthanasia through palliative care. Also the needs concerning palliative care for children as well as for chronic psycho-geriatrics patients are presented. Further attention is paid to the organisation of palliative care, focusing at evaluative research on palliative support teams, caring for caregivers (experiences and evaluation of interventions for palliative care teams), and effects of transmural care on coordination and continuity of care. Finally, some articles focus on ethical considerations in the treatment of pain in hospice movement, ethical evaluation of clinical trials in palliative care, and the role of informed consent in palliative radiotherapy, stressing the participation of patients and proxies in treatment decisions. Conclusions are presented on the consequences for educational and counselling aspects of palliative care.

The prevention of euthanasia through palliative care: new developments in The Netherlands.

Dutch palliative care stands on the eve of important changes. Further development of palliative care has become part of official national health care policy. One of the aims is prevention of euthanasia. Through an expansion and improvement of palliative care facilities it is trying to rule out the possibility that future requests of euthanasia might be brought about through insufficient and inadequate palliative care. This paper focuses on these new developments in The Netherlands. It first discusses the recent developments with regard to euthanasia. Thereafter, it describes the dynamic setting of palliative care. Finally, the issue of prevention of euthanasia through palliative care is analyzed. With regard to this topic, two questions need to be carefully distinguished. On the one hand, there is the factual question of whether a further development of palliative care can prevent euthanasia, on the other hand we have the normative question of whether palliative care should be further developed to prevent euthanasia. Both questions are analyzed.

Clinical trials in palliative care: an ethical evaluation.

On first sight, clinical trials do not seem to fit well within the concept of palliative care. In palliative care, the needs and wishes of the patient set the norm while participation in experimental trials is potentially harmful for the patient. The dilemma seems hard to solve as optimal care for the dying and improvement of treatment for future patients are both imperative. Yet, the one seems to exclude the other. However, on closer examination it becomes less evident that clinical trials in palliative care confront us with an unsolvable dilemma. Some patients' lives may gain meaning through participation in trials out of solidarity with future patients. In order to clarify this, the notions of authenticity and hope can be illuminative.

The troublesome concept of the person.

In today's bioethical debates, the concept of the person plays a major role. However, it does not hold this role justly. The purpose of this paper is to argue that the concept of the person is unsuited to be a central concept in bioethical debates, because its use is connected with serious problems. First, the concept is superfluous. Secondly, it is a confusing concept and it lacks pragmatic use. Thirdly, its use leads to simplifications. Finally, the concept can easily be used as a cover-up concept. Therefore, it is argued that relinquishing the concept of the person could enhance the clarity and quality of bioethical debate. Moreover, the historic origin of much of the present confusion surrounding the concept of the person is clarified. It is demonstrated that three influences resulting from Locke's ideas on the person and personal identity can be determined as contributing factors to the confusion and controversy within the present bioethical debates centering around the person.