Protection of Conscience Project Library

Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands

Johanna H. Groenewoud, Agnes van der Heide, Bregje D. Onwuteaka-Philipsen, Dick L Willems, Paul J van der Maas, Gerrit van der Wal

New England Journal of Medicine, NEJM — New England Journal of Medicine

Abstract
Background and Methods
The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death.

Results
In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).

Conclusions
There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide.

Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. N Engl J Med 2000; 342:551-556 February 24, 2000 DOI:10.1056/NEJM200002243420805

The Professional Autonomy of the Medical Doctor in Italy

Dario Sacchini, Leonardo Antico

Abstract
This contribution deals with the issue of the professional autonomy of the medical doctor. Worldwide, the physician’s autonomy is guaranteed and limited, first of all, by Codes of Medical Ethics. In Italy, the latest version of the national Code of Medical Ethics (Code 1998) was published in 1998 by the Federation of provincial Medical Asso- ciations (FNOMCEO). The Code 1998 acknowledges the physician’s autonomy regarding the scheduling, the choice and application of diagnostic and therapeutic means, within the principles of professional responsibility. This responsibility has to make reference to the following fundamental ethical principles: (1) the protection of human life; (2) the protection of the physical and psychological health of the human being; (3) the relief from pain; (4) the respect for the freedom and the dignity of the human person, without discrimination; (5) an up-to-date scientific qualification (Art. 5). The authors underline that autonomy is an anthropological – and consequently ethical – characteristic of the human person. Different positions on autonomy in bioethics (individualistic, evolutionistic, utilitarian and personalistic models) are explained. The relation between the professional autonomy of the physician and the autonomy of the patient and of colleagues is discussed. In fact, the medical doctor is obliged: (1) to respect the fundamental rights of the person, first of all his/her life; (2) to ensure the continuity of the care, even if he can only relieve the patient’s suffering; (3) to maintain, except under certain circumstances, professional secrecy and confidentiality regarding patients and their medical records. Moreover, the physician cannot deny the patient correct and appropriate information. He/she should not perform any diagnostic or therapeutic activity without the informed consent of the patient and the medical doctor must give up medical treatment in case of documented refusal of the individual. Furthermore, the medical doctor has the right to raise conscientious objections if he/she is requested to perform medical actions that are contrary to his/her conscience or medical opinion, unless this attitude would seriously and immediately harm the patient. Regarding the relationships with colleagues, the physician is obliged to solidarity, mutual respect, and care of sick colleagues. Finally, the authors discuss the Italian legislation affecting the physician’s professional autonomy: (1) the SSN health care Acts; (2) the so- called Charter for Public Health Care Services; (3) the Acts on privacy; (4) Good Clinical Practice.

Sacchini D, Antico L. The Professional Autonomy of the Medical Doctor in Italy. Theor Med Bioethics. 2000 Feb;21(1):441-456.

(News) With teen pregnancies skyrocketing, ob/gyns seek support for nonprescription “morning-after pill”

Barbara Sibbald

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Support for a move to make emergency postcoital contraception available without a prescription appears to be mushrooming in Canada. The Society of Obstetricians and Gynaecologists of Canada (SOGC) and 23 other medical and pharmaceutical organizations have joined the groundswell of support since the SOGC launched a campaign to increase awareness and availability of the “morning-after pill” in November 1998. . . some CPhA members feel emergency contraception “may interfere with implantation of the fertilized egg and they consider that more [like] abortion,” said Cooper. Pharmacists for Life, a Canadian group with about 10 members, has already opposed the move, even though the World Health Organization (WHO) says taking the drug is not equivalent to performing an abortion because the woman is not pregnant.

Sibbald B. With teen pregnancies skyrocketing, ob/gyns seek support for nonprescription “morning-after pill”. Can Med Assoc J. 1999 Oct 5;161(7):855.

Conscience clause: moral compromise

Chris Thatcher

Extract
Ask your pharmacist: It’s the ubiquitous slogan of the past decade, underscoring the campaigns of most national and provincial pharmacy organizations as they promote the value of pharmacy services. But what if the question is about RU-486, the abortion drug, or Preven, the morning-after-pill? What if the question is from a physician seeking information on terminal sedation or assisted suicide?

Such questions push, and often breach, an ethical boundary for some pharmacists, who find their desire to help the patient in conflict with their moral convictions. And the ethical quagmire is likely to get deeper as advocacy groups press the federal government to allow physician-assisted suicide and various health organizations promote greater access to emergency postcoital contraception.

If these practices compromise your moral convictions, could you be fired by your employer for refusing to fill a prescription? More specifically, is there a point at which your personal beliefs supersede your obligation to the patient? That’s the difficult question posed by an Alberta-based group called Concerned Pharmacists for Conscience, which has suggested a conscience clause to protect pharmacists in such situations.

Thatcher C. Conscience clause: moral compromise. Can Pharm J. 1999;132(7):10-11

(News) Leak of abortion information creates turmoil at Foothills

Richard Cairney

Extract

The Calgary Regional Health Authority (CRHA)has won a court judgement preserving the private, confidential nature of documents concerning genetic terminations of pregnancy that were leaked to Alberta Report by one or more angry pro-life nurses. . . .The controversy erupted after one or more members of the nursing staff at Foothills leaked confidential documents to the magazine. The resulting articles were filled with loaded language — “genetic terminations unquestionably constitute murder” and “the abortionist might well be guilty of culpable homicide” are 2 examples. . . ..

Cairney R. Leak of abortion information creates turmoil at Foothills. Can. Med. Assoc. J.. 1999;161(4):424-425.

Some ethical and legal issues in assisted reproductive technology

Bernard M Dickens, Rebecca J Cook

International Journal of Gynecology & Obstetrics

Abstract
The potential and actual applications of reproductive technologies have been reviewed by many governmental committees, and laws have been enacted in several countries to accommodate, limit and regulate their use. Regulatory systems have nevertheless left some legal and ethical issues unresolved, and have caused other issues to arise. Issues that regulatory systems leave unresolved, or that systems have created, include disposal of embryos that remain after patients’ treatments are concluded, and multiple implantation and pregnancy. This may result in risks to maternal, embryonic and neonatal life and health, and the contentious relief that may be achieved by selective reduction of multiple pregnancies. A further concern arises when clinics must or choose to publicize their success rates, and they compete for favorable statistics by questionable patient selection criteria and treatment priorities..

Dickens BM, Cook RJ. Some ethical and legal issues in assisted reproductive technology. Int J Gynecol Obstet. 1999;66(1) 55-61.

Crisis of Conscience: Reconciling Religious Health Care Providers’ Beliefs and Patients’ Rights

Katherine A White

Abstract
In this note, Katherine A. White explores the conflict between religious health care providers who provide care in accordance with their religious beliefs and the patients who want access to medical care that these religious providers find objectionable. Specifically, she examines Roman Catholic health care institutions and HMOs that follow the Ethical and Religious Directives for Catholic Health Care Services and considers other religious providers with similar beliefs. In accordance with the Directives, these institutions maintain policies that restrict access to “sensitive” services like abortion, family planning , HIV counseling, infertility treatment, and termination of life-support. White explains how most state laws protecting providers’ right to refuse treatments in conflict with religious principles do not cover this wide range of services. Furthermore, many state and federal laws and some court decisions guarantee patients the right to receive this care. The constitutional complication inherent in this provider-patient conflict emerges in White’s analysis of the interaction of the Free Exercise and Establishment Clauses of the First Amendment and patients’ right to privacy. White concludes her note by exploring the success of both provider-initiated and legislatively mandated compromise strategies. She first describes the strategies adopted by four different religious HMOs which vary in how they increase or restrict access to sensitive services. She then turns her focus to state and federal “bypass” legislation, ultimately concluding that increased state supervision might help these laws become more viable solutions to provider-patient conflicts.

White KA. Crisis of Conscience: Reconciling Religious Health Care Providers’ Beliefs and Patients’ Rights. Stanford Law Rev. 1999 Jul;51(6)1703-1749.

(Thesis) Conscientious objectors to a medical treatment: What are the rules?

Andre Carebonneau

Abstract
Patients who refuse a specific medical treatment for religious reasons must often overcome strongly entrenched presumptions held by physicians and judges, presumptions frequently based on personal values. A case in point is the refusal of blood transfusion therapy by Jehovah’s Witnesses. This paper rests on the following theory: The sanctity of life principle is not necessarily violated by respecting the autonomous decision of a patient who, for religious or moral reasons, chooses one therapy over another that may be favored by the treating physician. Where a patient has decided for conscientious reasons against a certain treatment in any given medical situation, the need to be informed will shift from the patient to the physician. The physician must understand the nature of the religious or moral conviction as well as his own moral and legal obligation to respect the patient’s wishes by providing the best Medical care under the circumstances.

Carebonneau A. (Thesis) Conscientious objectors to a medical treatment: What are the rules [masters thesis]. [Montreal, PQ]: McGill Univesity; 1999 Jul. 122 p.

(News) Task force offers $547,000 to solve shootings (of abortion practitioners)

Barbara Sibbald

Extract
In all, 9 police forces on both sides of the border are investigating 5 incidents that are believed to be linked. All took place around Remembrance Day, all the physicians involved performed abortions and all were shot in their homes. The injured include Dr. Garson Romalis of Vancouver (1994), Dr. Hugh Short of An- caster, Ont. (1995), an unnamed Richmond, NY, physician (1996) and Dr. Jack Fainman of Winnipeg (1997). The first fatality occurred last Oct. 23 when Slepian was shot and killed at his home. An American murder warrant has been issued for Vermont antiabortion activist James Kopp, 44. Kopp, whose whereabouts are a mystery, is charged only in the slaying of Slepian. He remains a “person of interest” in connection with the other shootings.

Sibbald B. Task force offers $547,000 to solve shootings (of abortion practitioners). Can Med Assoc J. 1999 Jun 15;160(12).

The Common Good and the Duty to Represent: Must the Last Lawyer in Town Take Any Case?

Teresa Stanton Collett

Extract
More specifically, this article explores the question: Is it morally permissible for a lawyer to decline representation of a prospective client who seeks to obtain a legal but immoral objective, if the lawyer reasonably believes that the prospective client will be otherwise unable to obtain legal representation?

Collett TS. The Common Good and the Duty to Represent: Must the Last Lawyer in Town Take Any Case? South Texas Law Review. 1999;40(137-179)