Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

The Netherlands is one of the few countries where euthanasia is legal under strict conditions. This study investigates whether Dutch newspaper articles use the term ‘euthanasia’ according to the legal definition and determines what arguments for and against euthanasia they contain.

BackgroundAn important principle underlying the Dutch Euthanasia Act is physicians' responsibility to alleviate patients' suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians (...) to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees' attention.MethodsWe examined 158 files of reported euthanasia and physician-assisted suicide cases that were approved by the review committees. We studied the physicians' reports and the verdicts of the review committees by using a checklist.ResultsPhysicians reported that the patient's request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients' suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient's (unbearable) suffering (32%); they had few questions about possible alternatives (1%).ConclusionDutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees' control seems to focus on (unbearable) suffering and on procedural issues. (shrink)

The Dutch law states that a physician may perform euthanasia according to a written advance euthanasia directive when a patient is incompetent as long as all legal criteria of due care are met. This may also hold for patients with advanced dementia. We investigated the differing opinions of physicians and members of the general public on the acceptability of euthanasia in patients with advanced dementia.

Although euthanasia and assisted suicide in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients. A survey was distributed amongst a random sample of Dutch 2641 citizens and 3000 physicians. Acceptance and conceivability of (...) performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed. Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered. The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria. (shrink)

Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Background Studies describing physicians’ experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation.Methods Qualitative face-to-face interviews were held in 2007–2008 with 36 physicians , including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses.Results In both countries, the use of sedation (...) was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives.Conclusions The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.

Background: Debates over legalisation of physician-assisted suicide or euthanasia often warn of a “slippery slope”, predicting abuse of people in vulnerable groups. To assess this concern, the authors examined data from Oregon and the Netherlands, the two principal jurisdictions in which physician-assisted dying is legal and data have been collected over a substantial period.Methods: The data from Oregon comprised all annual and cumulative Department of Human Services reports 1998–2006 and three independent studies; the data from the Netherlands comprised all four (...) government-commissioned nationwide studies of end-of-life decision making and specialised studies. Evidence of any disproportionate impact on 10 groups of potentially vulnerable patients was sought.Results: Rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured , people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS. While extralegal cases were not the focus of this study, none have been uncovered in Oregon; among extralegal cases in the Netherlands, there was no evidence of higher rates in vulnerable groups.Conclusions: Where assisted dying is already legal, there is no current evidence for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician-assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges. (shrink)

Animal welfare scientific literature has accumulated rapidly in recent years, but bias may exist which influences understanding of progress in the field. We conducted a survey of articles related to animal welfare or well being from an electronic database. From 8,541 articles on this topic, we randomly selected 115 articles for detailed review in four funding categories: government; charity and/or scientific association; industry; and educational organization. Ninety articles were evaluated after unsuitable articles were rejected. The welfare states of animals in (...) new treatments, conventional treatments or control groups with no treatment were classified as high, medium or low according to one or more. More articles were published in which the welfare of animals in new treatments was better than that of animals in the conventional or no treatment groups, demonstrating a positive result bias. Failure to publish studies with negative or inconclusive results may lead to other scientists unnecessarily repeating the research. The authors’ assessments of the welfare state of the groups were similarly rated high, medium or low, and it was found that new treatments were rated lower if the research was funded by industry, and higher when funded by charities, with government funding agencies intermediate. These differences were not evident in the Five Freedoms assessment, demonstrating an authors’ assessment bias that appeared to support the funding agencies’ interests. North American funded publications rated the welfare of animals in New treatments higher and those in a Conventional or No Treatment lower, compared with European-funded publications. It is concluded that preliminary evidence was provided of several forms of publication bias in animal welfare science. (shrink)

Introduction: The Dutch Euthanasia Act states that euthanasia is not punishable if the attending physician acts in accordance with the statutory due care criteria. These criteria hold that: there should be a voluntary and well-considered request, the patient’s suffering should be unbearable and hopeless, the patient should be informed about their situation, there are no reasonable alternatives, an independent physician should be consulted, and the method should be medically and technically appropriate. This study investigates whether physicians experience problems with these (...) criteria in medical practice.Methods: In 2006, questionnaires were sent to a random, stratified sample of 2100 Dutch physicians . Physicians were asked about problems in their decision-making related to requests for euthanasia or assisted suicide after enforcement of the 2002 Euthanasia Act.Results: Of all physicians who had received a request for euthanasia or assisted suicide , 25% had experienced problems in the decision-making with regard to at least one of the criteria of due care. Physicians who had experienced problems mostly indicated to have had problems related to evaluating whether or not the patient’s suffering was unbearable and hopeless and whether or not the patient’s request was voluntary or well considered .Discussion: Physicians in The Netherlands most frequently reported problems related to aspects in which they have to evaluate the patient’s subjective perspective. However, it can be questioned whether placing emphasis on these subjective aspects is an adequate fulfilment of the duties imposed on physicians, as laid down in the Dutch Euthanasia Act. (shrink)

Introduction: In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. Methods: 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a “standard case” of a patient with physical suffering and limited life expectancy, the descriptions included cases in (...) which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. Results: The cases were recognisable for almost all respondents. For the “standard case” nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2–49%) than consultants (25–79%) and members of the euthanasia review committees (24–88%). In each group, the suffering of patients with early dementia and patients who were “tired of living” was least often considered to be unbearable. Conclusions: When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient’s suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia. (shrink)

Introduction In 2007, a national review committee was instituted in The Netherlands to review cases of active ending of life for newborns. It was expected that 15–20 cases would be reported. To date, however, only one case has been reported to this committee. Reporting is essential to obtain societal control and transparency; the possible explanations for this lack of reporting were therefore explored. Methods Data on end-of-life decision-making were scrutinised from Dutch nation-wide studies (1995, 2001 and 2005), before institution of (...) the committee. Physicians received a questionnaire about their medical decision-making for stratified samples of deceased infants up to 1 year, drawn from the central death registry. Results In 2005, 58% of all deaths were preceded by an end-of-life decision, compared with 68% in 2001 and 62% in 1995. The use of drugs with a possible life-shortening effect tended to be lower. In 2005, all four cases in the study in which an infants' life was actively ended were preceded by a decision to forego life-prolonging treatment. In three cases, the infant's life expectancy was short; one case involved a longer life expectancy. Discussion The expected number of cases is probably an overestimation due to changes in medical practice such as the tendency to attribute less life-shortening effects to opioids. The lack of reports is probably also associated with requirements in the regulation; it may be difficult to fulfil them due either to time constraints or the nature of the suffering that is addressed. If societal control of active ending of life is considered useful, changes in the regulation may be needed. (shrink)

Aan het eind van Zur Genealogie der Moral kondigt Nietzsche aan dat hij later een boek zal schrijven over ‘de geschiedenis van het Europese nihilisme’ . Dat boek is er nooit gekomen, althans niet van Nietzsches hand. Het enige wat we hebben zijn de aantekeningen daarvoor in zijn nalatenschap. Een van die notities is het beroemde ‘Lenzer Heide Ontwerp’ , een tekst waaraan Nietzsche zelf de titel Het Europese nihilisme gaf.Nadat Nietzsche de winter van 1886/87 in Nice had doorgebracht, (...) trok hij in het voorjaar weer richting Zwitserland om zich voor de zomer in Sils Maria te vestigen. In Nice had hij juist Dostojevski ontdekt, van wie hij onder andere de Aantekeningen uit het ondergrondse las, een boek dat een zeer kritische psychologie van de nihilist bevat. Op zijn reis naar het Engadin bleef Nietzsche steken omdat het in het hooggebergte nog te koud was en de Julier-pas nog niet sneeuwvrij. Tijdens zijn gedwongen oponthoud in Lenzer Heide noteerde hij deze tekst, aan de hand waarvan we nu een paar elementen van Nietzsches analyse van het Europese nihilisme belichten. (shrink)

Can a person’s degree of wellbeing be affected by things that do not enter her experience? Experientialists deny that it can, extra-experientialists affirm it. The debate between these two positions has focused on an argument against experientialism—the experience machine objection—but few arguments exist for it. I present an argument for experientialism. It builds on the claim that theories of wellbeing should not only state what constitutes wellbeing, but also which entities are welfare subjects. Moreover, the claims it makes about these (...) two issues should have a certain coherence with each other. I argue that if we accept a particular plausible answer to the second question—namely that all and only sentient beings are welfare subjects—extra-experientialist theories face a problem of coherence. While this problem can typically be solved, doing so will involve steps that are unattractive. On experientialist theories, on the other hand, the answer to these questions cohere perfectly. (shrink)

In Anarchy, State, and Utopia, Robert Nozick contrasts entitlement theories of justice and “traditional” theories such as Rawls', utilitarianism or egalitarianism, and advocates the former against the latter. What exactly is an entitlement theory of justice? Nozick's book offers two distinct characterizations. On the one hand, he explicitly describes “the general outlines of the entitlement theory” as maintaining “that the holdings of a person are just if he is entitled to them by the principles of justice in acquisition and transfer, (...) or by the principle of rectification of injustice ”. On the other hand, his famous “Wilt Chamberlain” argument against alternative theories is first said to apply to “non-entitlement conceptions”, and later to any “end-state principle or distributional patterned principle of justice” — which amounts to an implicit characterization of an entitlement conception as a conception of justice which is neither end-state nor patterned. (shrink)

It is often alleged that Cantor’s views about how the set theoretic universe as a whole should be considered are fundamentally unclear. In this article we argue that Cantor’s views on this subject, at least up until around 1896, are relatively clear, coherent, and interesting. We then go on to argue that Cantor’s views about the set theoretic universe as a whole have implications for theology that have hitherto not been sufficiently recognised. However, the theological implications in question, at least (...) as articulated here, would not have satisfied Cantor himself. (shrink)

Phenomenological healthcare research should include the lived experiences of a broad group of healthcare users. In this paper it is shown how shadowing can give a voice to people in vulnerable situations who are often excluded from interview studies. Shadowing is an observational method in which the researcher observes an individual during a relatively long time. Central aspects of the method are the focus on meaning expressed by the whole body, and an extended stay of the researcher in the phenomenal (...) event itself. Inherent in shadowing is a degree of ambivalence that both challenges the researcher and provides meaningful insights about the phenomenon. A case example of a phenomenological study on the experiences of elderly hospital patients is used to show what shadowing yields. (shrink)

The image of “the good nurse” is mainly studied from the perspective of nurses, which often does not match the image held by patients. Therefore, a descriptive study was conducted to examine oncology patients’ perceptions of “the good nurse” and the influence of patient- and context-related variables. A cross-sectional, comparative, descriptive design was used. The sample comprised 557 oncology patients at one of six Flemish hospitals, where they were treated in an oncology day-care unit, oncology hospital ward, or palliative care (...) unit. Data were collected using the Flemish Care-Q instrument. Factor analysis summarised the most important characteristics of “the good nurse”. We reassessed the reliability and construct validity of the Flemish Care-Q and examined the influence of patient- and context-related variables on patient perceptions. Using factor analysis, we grouped the different items of the Flemish Care-Q according to three characteristics: “the good nurse” (I) has a supportive and communicative attitude towards patient and family, (II) is competent and employs a professional attitude, and (III) demonstrates personal involvement towards patient and family. Median factor scores of Factors I, II, and III, respectively, were 8.00, 9.00, and 8.00 (varying from 1, not important, to 10, very important). In order of importance, Factors II, I, and III were identified as valuable characteristics of “the good nurse”. Gender, care setting, and province were influential variables. As perceived by oncology patients, “the good nurse” has a broad range of qualities, of which competence and professionalism are the most valuable. (shrink)

Fitch showed that not every true proposition can be known in due time; in other words, that not every proposition is knowable. Moore showed that certain propositions cannot be consistently believed. A more recent dynamic phrasing of Moore-sentences is that not all propositions are known after their announcement, i.e., not every proposition is successful. Fitch's and Moore's results are related, as they equally apply to standard notions of knowledge and belief (S 5 and KD45, respectively). If we interpret ‘successful’ as (...) ‘known after its announcement’ and ‘knowable’ as ‘known after some announcement’, successful implies knowable. Knowable does not imply successful: there is a proposition ϕ that is not known after its announcement but there is another announcement after which ϕ is known. We show that all propositions are knowable in the more general sense that for each proposition, it can become known or its negation can become known. We can get to know whether it is true: ◊(Kϕ ∨ K¬ϕ). This result comes at a price. We cannot get to know whether the proposition was true. This restricts the philosophical relevance of interpreting ‘knowable’ as ‘known after an announcement’. (shrink)

This paper reinvestigates the question of liberal neutrality. We contend that current liberal discussions have been dominated—if not hijacked—by one particular interpretation of what neutrality could imply: namely, exclusive neutrality, aiming to exclude religious and cultural expressions from the public sphere. We will argue that this is merely one among several relevant interpretations. To substantiate our claim, we will first elaborate upon inclusive neutrality by formulating two supplementary interpretations: proportional neutrality and compensatory neutrality. Second, we will argue that inclusive proportional (...) neutrality is the most appropriate interpretation in many contexts. Our discussion highlights the fact that some political disputes should not be seen in terms of the antithesis between liberal neutrality and illiberal alternatives but, instead, as a clash between various valid but incompatible interpretations of what liberal neutrality may imply. (shrink)

Research on self-agency emphasizes the importance of a comparing mechanism, which scans for a match between anticipated and actual outcomes, in the subjective experience of doing.This study explored the “feeling of doing” in individuals with checking symptoms by examining the mechanism involved in the experienced agency for outcomes that matched expectations. This mechanism was explored using a task in which the subliminal priming of potential action-effects generally enhances people’s feeling of causing these effects when they occur, due to the unconscious (...) perception of a match between primed and observed outcomes. The main result revealed a negative relationship between checking and self-agency for observed outcomes that were primed prior to actions. This suggests that checking individuals fail to grasp the correspondence between actual outcomes of their actions and expected ones. We discuss the possible role of undermined self-agency in checking phenomena and its relationship with cognitive dysfunction. (shrink)

ABSTRACTIn The Netherlands, the public funding of a number of health care services is controversial. What can we learn from this about the moral concerns that underlie these judgements? And, if there is anything to learn, can we use this improved understanding to scrutinise the adequacy of particular decisions concerning the public funding of health care services? In the present paper, I will analyse three cases: corrective surgey, In Vitro Fertilisation and liver transplantation. I will summarise the arguments that have (...) been used to support or to challenge the public funding of these services. I will then assess the merits of Daniels’fair equality of opportunity account of justice in health care. Can this account improve our understanding of the moral concerns underlying our judgements about the public funding of these services? Can it serve to scrutinise the adequacy of particular decisions that are made concerning the public funding of health care services? My answer to both questions will be a qualified yes. Daniels’account can provide guidance, but not because we can deductively infer from it what is right and what is wrong. Instead, I will argue for a more casuistic use of the concept of fair equality of opportunity. (shrink)

In this article, the conceptual instrument that pragma-dialectical argumentation theory offers is elaborated for the analysis and evaluation of problem-solving discussions. The elaboration is aimed expressly at taking into account the discussion character of the discourse, in order to show how the developing process evolves and what the obstacles are therein. In addition, it focuses expressly on the verbal behaviour of the participants and on showing how this behaviour controls the evolving process. The analysis and evaluation is based on insights (...) and methods of conversational analysis and discourse analysis. One fragment of a problem-solving discussion is analysed and evaluated. (shrink)