Gerrit K. Kimsma

Medical students' cases as an empirical basis for teaching clinical ethics.

Purpose To identify ethical issues that interns encounter in their clinical education and thus build a more empirical basis for the required contents of the clinical ethics curriculum. Method The authors analyzed a total of 522 required case reports on ethical dilemmas experienced by interns from September 1995 to May 1999 at the medical school of Vrije Universiteit in Amsterdam. They identified four regularly described and numerous less frequently described topics. Results The interns addressed a wide range of ethical themes. In 45% of the cases, they mentioned disclosure or non-disclosure of information and informed consent; in 37%, medical decisions at the end of life; in 16%, medical failures; and in 9%, problems transferring patients from one caregiver to another. The interns also identified 27 themes linked to their unique position as interns and 19 themes related to specific types of patients. Conclusion Based on self-reported experiences, the authors conclude that clinical ethics teachers should reflect on a multitude of dilemmas. Special expertise is required with respect to end-of-life decisions, truth telling, medical failures, and transferring patients from one caregiver to another. The clinical ethics curriculum should encourage students to voice their opinions and deal with values, responsibilities, and the uncertainty and failings of medical interventions.

Euthanasia and Assisted Suicide: Facts, Figures and Fancies with Special Regard to Old Age

The objective of this paper is to describe the ethics and incidence of euthanasia and physician-assisted suicide (EAS) with special regard to old age. It is based on an assumption that if and when a practice of euthanasia and EAS is allowed, several vulnerable groups, including the elderly, may become a ‘population at risk’.We describe some of these claims, and make an inventory of the arguments against a permissive policy concerning euthanasia and EAS which emphasise inherent dangers for the elderly. We then give an overview of the results of empirical studies about incidence of (request for) euthanasia and assisted suicide in the Netherlands, Australia, the UK, the US, Denmark and Norway. These results confirm that practitioners do receive requests for EAS and that EAS is performed in all these countries. However, there are large differences between these countries with regard to the numbers of requests and performances. Dutch findings concerning the age distribution of patients who received euthanasia or assisted suicide indicate that these procedures are rare in the elderly and in nursing homes.We conclude that, although euthanasia and assisted suicide are illegal, there is evidence that these practices occur in all countries studied. Most surveys on the incidence of euthanasia show lower figures than those in the Netherlands. Dutch studies do not provide any evidence for the elderly being in danger of becoming ‘victims’ of euthanasia or assisted suicide.

End-of-life care in The Netherlands and the United States: a comparison of values, justifications, and practices

Voluntary active euthanasia (VAE) and physician-assisted suicide (PAS) remain technically illegal in the Netherlands, but the practices are openly tolerated provided that physicians adhere to carefully constructed guidelines. Harsh criticism of the Dutch practice by authors in the United States and Great Britain has made achieving a balanced understanding of its clinical, moral, and policy implications very difficult. Similar practice patterns probably exist in the United States, but they are conducted in secret because of a more uncertain legal and ethical climate. In this manuscript, we plan to compare end-of-life care in the United States and the Netherlands with regard to underlying values, justifications, and practices. We will explore the risks and benefits of each system for a real patient who was faced with a common end-of-life clinical dilemma, and close with challenges for public policies in both countries.

Philosophy of Medical Practice: A Discursive Approach

In spite of the seminal work A Philosophical Basis of Medical Practice, the debate on the task and goals of philosophy of medicine still continues. From an European perspective it is argued that the main topics dealt with by Pellegrino and Thomasma are still particularly relevant to medical practice as a healing practice, while expressing the need for a philosophy of medicine. Medical practice is a discursive practice which is highly influenced by other discursive practices like science, law and economics. Philosophical analysis of those influences is needed to discern their effect on the goals of medicine and on the ways in which the self-image of man may be changed. The nature of medical practice and discourse itself makes it necessary to include different philosophical disciplines, like philosophy of science, of law, ethics, and epistemology. Possible scenarios of euthanasia and the human genome project in the USA and Europe are used to exemplify how philosopy of medicine can contribute to a realistic understanding of the problems which are related to the goals of medicine and health care.

Euthanasia and Assisted Suicide in the Netherlands and the USA: Comparing Practices, Justifications and Key Concepts in Bioethics and Law

Euthanasia and physician assisted suicide remain controversial in the United States of America, in the Netherlands, and in other western countries. Debates involve highly abstract and technical problems, situated at the intersection of ethics, law, and medicine; nevertheless, they have a very public character. The issues are broadly discussed in the media and elsewhere. The key concepts and definitions of euthanasia and physician assisted suicide differ between countries and their legal and medical traditions, fueling confusion and misunderstanding. For example, American debates cite the practice of ending lives under medical care in the Netherlands both as an example to follow and as one to refrain from at all costs. Even though the Northern Territories of Australia technically was the first place in the world to legalize euthanasia and assisted suicide, the Dutch experience continues to draw more attention from Americans. The figures published in Dutch studies are used and abused by Dutch and non-Dutch authors alike. The experiences of physicians and patients are cited to support a climate of death with dignity or to paint a picture of fear of physicians, lack of adequate care and legal permissiveness, resulting in the inability to hold the line between voluntary and involuntary euthanasia.

Euthanasia Drugs in the Netherlands

The use of the right drug in the right dose via the right route at the right time is a fundamental pharmacologic principle in the proper administration of all medications. It makes sense then that this standard should carry over to medications administered as a “euthanaticum.” The Dutch use this term for a medications used to bring about death in cases of euthanasia. Until quite recently, however, the pharmaceutical aspects of euthanasia and physician assisted suicide had received little attention. Here again, the Dutch experience is valuable in understanding some of the complexities of euthanasia, particularly the role of appropriate pharmacology.

Problems Involved in the Moral Justification of Medical Assistance in Dying: Coming to Terms with Euthanasia and Physician-Assisted Suicide

The Dutch practice of euthanasia and physician-assisted suicide has been followed by several political proposals to legalize medical assistance in dying. Short of legalization, the 1995 report of van der Wal and van der Maas has been especiallyused to broach a discussion about the possibility of an intermediate “solution” midway between criminalization and decriminalization of physician-assisted suicide. This solution involved inaugurating regional committees intended to supervise and check these acts with respect to their conformity to legal and medical conditions. These committees would serve as an intermediate position between the law and the physicians. It is expected that this procedure will bridge the gap between legal and medical ethical perspectives, stimulating and inviting physicians to report the active ending of lives. In this paper the inauguration of regional committees will be discussed with respect to the legal and moral issues of the practice of actively ending lives within the context of care. In the final part corollary philosophical issues will be analyzed.

Been There: Physicians Speak for Themselves

Some years ago I received the following letter from a friend who became my patient. In pursuit of my ultimate objective of being in control of my self-deliverance at the time when my physical condition no longer warrants continuance, I have joined the Hemlock Society of Los Angeles. The Society urges its members to explore with their personal physicians this subject well in advance of the actual moment of necessity, and in particular the problem of acquiring a lethal dose of a drug that will provide a release consistent in quality with the degree of peace and serenity sought in life. It is my hope that we can find a process commensurate with your moral and professional concerns which will allow us to collaborate.

Shifts in the direction of Dutch bioethics: forward or backward?

Important bioethcs changes are underway in the Netherlands that carry, for better or worse, far-reaching social consequences. The two major areas of change involve (1) economics and containing soaring health costs and (2) end-of-life care as reflected in several high-profile cases: in a decision handed down by the Dutch Supreme Court on reviewing the procedures for the termination of life, in the discussion surrounding The Groningen Protocol and the active ending of lives in neonatology, and in a report of a Royal Dutch Medical Societys Committee on the role of physicians in ending life in cases of requests to die outside the area of terminal diseases.