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1.  Role and Involvement of Life End Information Forum Physicians in Euthanasia and Other End-of-Life Care Decisions in Flanders, Belgium 
Health Services Research  2009;44(6):2180-2192.
Objective
To describe role and involvement of Life End Information Forum (LEIF) physicians in end-of-life care decisions and euthanasia in Flanders.
Study Design
All 132 LEIF physicians in Belgium received a questionnaire inquiring about their activities in the past year, and their end-of-life care training and experience.
Principal Findings
Response rate was 75 percent. Most respondents followed substantive training in end-of-life care. In 1 year, LEIF physicians were contacted 612 times for consultations in end-of-life decisions, of which 355 concerned euthanasia requests eventually resulting in 221 euthanasia cases. LEIF physicians also gave information about various end-of-life issues (including palliative care) to patients and colleagues.
Conclusions
LEIF physicians provide a forum for information and advice for physicians and patients. A similar health service providing support to physicians for all end-of-life decisions could also be beneficial for countries without a euthanasia law.
doi:10.1111/j.1475-6773.2009.01042.x
PMCID: PMC2796321  PMID: 19780854
Consultation; euthanasia; end-of-life decisions
2.  Euthanasia in patients dying at home in Belgium: interview study on adherence to legal safeguards 
The British Journal of General Practice  2010;60(573):e163-e170.
Background
Euthanasia became legal in Belgium in 2002. Physicians must adhere to legal due care requirements when performing euthanasia; for example, consulting a second physician and reporting each euthanasia case to the Federal Review Committee.
Aim
To study the adherence and non-adherence of GPs to legal due care requirements for euthanasia among patients dying at home in Belgium and to explore possible reasons for non-adherence.
Design of study
Large scale, retrospective study.
Setting
General practice in Belgium.
Method
A retrospective mortality study was performed in 2005–2006 using the nationwide Belgian Sentinel Network of General Practitioners. Each week GPs reported medical end-of-life decisions taken in all non-sudden deaths of patients in their practice. GP interviews were conducted for each euthanasia case occurring at home.
Results
Interviews were conducted for nine of the 11 identified euthanasia cases. Requirements concerning the patient's medical condition were met in all cases. Procedural requirements such as consultation of a second physician were sometimes ignored. Euthanasia cases were least often reported (n = 4) when the physician did not regard the decision as euthanasia, when only opioids were used to perform euthanasia, or when no second physician was consulted. Factors that may contribute to explaining non-adherence to the euthanasia law included: being unaware of which practices are considered to be euthanasia; insufficient knowledge of the euthanasia law; and the fact that certain procedures are deemed burdensome.
Conclusion
Substantive legal due care requirements for euthanasia concerning the patient's request for euthanasia and medical situation were almost always met by GPs in euthanasia cases. Procedural consultation and reporting requirements were not always met.
doi:10.3399/bjgp10X483940
PMCID: PMC2845507  PMID: 20353662
euthanasia; health policy; terminal care
3.  A protocol for consultation of another physician in cases of euthanasia and assisted suicide 
Journal of Medical Ethics  2001;27(5):331-337.
Objective—Consultation of another physician is an important method of review of the practice of euthanasia. For the project "support and consultation in euthanasia in Amsterdam" which is aimed at professionalising consultation, a protocol for consultation was developed to support the general practitioners who were going to work as consultants and to ensure uniformity.
Participants—Ten experts (including general practitioners who were experienced in euthanasia and consultation, a psychiatrist, a social geriatrician, a professor in health law and a public prosecutor) and the general practitioners who were going to use the protocol.
Evidence—There is limited literature on consultation: discursive articles and empirical studies describing the practice of euthanasia.
Consensus—An initial draft on the basis of the literature was commented on by the experts and general practitioners in two rounds. Finally, the protocol was amended after it had been used during the training of consultants.
Conclusions—The protocol differentiates between steps that are necessary in a consultation and steps that are recommended. Guidelines about four important aspects of consultation were given: independence, expertise, tasks and judgment of the consultant. In 97% of 109 consultations in which the protocol was used the consultant considered the protocol to be useful to a greater or lesser extent. Although this protocol was developed locally, it also employs universal principles. Therefore it can be of use in the development of consultation elsewhere.
Key Words: Euthanasia • assisted suicide • consultation • quality assurance • protocol
doi:10.1136/jme.27.5.331
PMCID: PMC1733456  PMID: 11579191
4.  Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey 
Background
Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.
Methods
We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.
Results
The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient’s explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.
Interpretation
Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.
doi:10.1503/cmaj.091876
PMCID: PMC2882449  PMID: 20479044
5.  Facing requests for euthanasia: a clinical practice guideline 
Journal of Medical Ethics  2004;30(2):212-217.
On 23 September 2002, the Belgian law on euthanasia came into force. This makes Belgium the second country in the world (after the Netherlands) to have an Act on euthanasia. Even though there is currently legal regulation of euthanasia in Belgium, very little is known about how this legal regulation could be translated into care for patients who request euthanasia.
doi:10.1136/jme.2003.005082
PMCID: PMC1733828  PMID: 15082821
6.  Nurses' views on their involvement in euthanasia: a qualitative study in Flanders (Belgium) 
Journal of Medical Ethics  2006;32(4):187-192.
Background
Although nurses worldwide are confronted with euthanasia requests from patients, the views of palliative care nurses on their involvement in euthanasia remain unclear.
Objectives
In depth exploration of the views of palliative care nurses on their involvement in the entire care process surrounding euthanasia.
Design
A qualitative Grounded Theory strategy was used.
Setting and participants
In anticipation of new Belgian legislation on euthanasia, we conducted semistructured interviews with 12 nurses working in a palliative care setting in the province of Vlaams‐Brabant (Belgium).
Results
Palliative care nurses believed unanimously that they have an important role in the process of caring for a patient who requests euthanasia, a role that is not limited to assisting the physician when he is administering life terminating drugs. Nurses' involvement starts when the patient requests euthanasia and ends with supporting the patient's relatives and healthcare colleagues after the potential life terminating act. Nurses stressed the importance of having an open mind and of using palliative techniques, also offering a contextual understanding of the patient's request in the decision making process. Concerning the actual act of performing euthanasia, palliative care nurses saw their role primarily as assisting the patient, the patient's family, and the physician by being present, even if they could not reconcile themselves with actually performing euthanasia.
Conclusions
Based on their professional nursing expertise and unique relationship with the patient, nurses participating as full members of the interdisciplinary expert team are in a key position to provide valuable care to patients requesting euthanasia.
doi:10.1136/jme.2005.011783
PMCID: PMC2565778  PMID: 16574869
euthanasia; palliative care; nursing; qualitative research; Grounded Theory; ethics
7.  Requests for euthanasia in general practice before and after implementation of the Dutch Euthanasia Act 
Background
The Netherlands was the first country in the world to implement a Euthanasia Act in 2002. It is unknown whether legalising euthanasia under strict conditions influences the number and nature of euthanasia requests.
Aim
To investigate changes in the number of, and reasons for, requests for euthanasia in Dutch general practice after implementation of the Euthanasia Act.
Design of study
Retrospective dynamic cohort study comparing 5 years before (1998–2002) and 5 years after (2003–2007) implementation of the Act.
Method
Standardised registration forms were used to collect data on requests for euthanasia via the Dutch Sentinel Practice Network. This network of 45 general practices is nationally representative by age, sex, geographic distribution, and population density.
Results
The mean annual incidence of requests before implementation amounted to 3.1/10 000 and thereafter to 2.8/10 000 patients. However, trends differed by sex. The number of requests by males decreased significantly from 3.7/10 000 to 2.6/10 000 (P = 0.008); the requests by females increased non-significantly from 2.6/10 000 to 3.1/10 000. Before and after implementation, cancer remained the major underlying disease for requesting euthanasia: 82% versus 77% for men; 73% versus 75% for females. Pain was a major reason for a request, increasing in the period before implementation (mean 27%), but declining in the period thereafter (mean 22%). Loss of dignity became a less important reason after implementation (from 18% to 10%, P = 0.04), predominantly due to a marked decrease in the number of females citing it as a reason (from 17% to 6%, P = 0.02).
Conclusion
There was no increase in demand for euthanasia after implementation of the Euthanasia Act. Pain as a reason for requesting euthanasia showed an increasing trend before implementation, but declined thereafter. Loss of dignity as a reason declined, especially in females.
doi:10.3399/bjgp10X483931
PMCID: PMC2845488  PMID: 20353671
death; epidemiology; euthanasia; euthanasia Act; family practice; legislation; palliative care
8.  News media coverage of euthanasia: a content analysis of Dutch national newspapers 
BMC Medical Ethics  2013;14:11.
Background
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.
Methods
We did an electronic search of seven Dutch national newspapers between January 2009 and May 2010 and conducted a content analysis.
Results
Of the 284 articles containing the term ‘euthanasia’, 24% referred to practices outside the scope of the law, mostly relating to the forgoing of life-prolonging treatments and assistance in suicide by others than physicians. Of the articles with euthanasia as the main topic, 36% described euthanasia in the context of a terminally ill patient, 24% for older persons, 16% for persons with dementia, and 9% for persons with a psychiatric disorder. The most frequent arguments for euthanasia included the importance of self-determination and the fact that euthanasia contributes to a good death. The most frequent arguments opposing euthanasia were that suffering should instead be alleviated by better care, that providing euthanasia can be disturbing, and that society should protect the vulnerable.
Conclusions
Of the newspaper articles, 24% uses the term ‘euthanasia’ for practices that are outside the scope of the euthanasia law. Typically, the more unusual cases are discussed. This might lead to misunderstandings between citizens and physicians. Despite the Dutch legalisation of euthanasia, the debate about its acceptability and boundaries is ongoing and both sides of the debate are clearly represented.
doi:10.1186/1472-6939-14-11
PMCID: PMC3599791  PMID: 23497284
Euthanasia; Media; Content analysis
9.  Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study 
BMC Medical Ethics  2009;10:18.
Background
An 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.
Methods
We 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.
Results
Physicians 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%).
Conclusion
Dutch 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.
doi:10.1186/1472-6939-10-18
PMCID: PMC2781018  PMID: 19860873
10.  Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium 
BMC Public Health  2009;9:79.
Background
This study compares prevalence and types of medical end-of-life decisions between the Dutch-speaking and French-speaking communities of Belgium. This is the first nationwide study that can make these comparisons and the first measurement after implementation of the euthanasia law (2002).
Methods
We performed a mortality follow-back study in 2005–2006. Data were collected via the nationwide Sentinel Network of General Practitioners, an epidemiological surveillance system representative of all Belgian GPs.
Weekly, all GPs reported the medical end-of-life decisions among all non-sudden deaths of patients in their practice. We compared the northern Dutch-speaking (60%) and southern French-speaking communities (40%) controlling for population differences.
Results
We analysed 1690 non-sudden deaths. An end-of-life decision with possible life-shortening effect was made in 50% of patients in the Dutch-speaking community and 41% of patients in the French-speaking community (OR 1.4; 95%CI, 1.2 to 1.8). Continuous deep sedation until death occurred in 8% and 15% respectively (OR 0.5; 95%CI, 0.4 to 0.7). Community differences regarding the prevalence of euthanasia or physician-assisted suicide were not significant.
Community differences were more present among home/care home than among hospital deaths: non-treatment decisions with explicit life-shortening intention were made more often in the Dutch-speaking than in the French-speaking community settings (OR 2.2; 95%CI, 1.2 to 3.9); while continuous deep sedation occurred less often in the Dutch-speaking community settings (OR 0.5; 95%CI, 0.3 to 0.9).
Conclusion
Even though legal and general healthcare systems are the same for the whole country, there are considerable variations between the communities in type and prevalence of certain end-of-life decisions, even after controlling for population differences.
doi:10.1186/1471-2458-9-79
PMCID: PMC2660906  PMID: 19272153
11.  Euthanasia in family practice in The Netherlands. Toward a better understanding. 
Canadian Family Physician  1997;43:231-237.
OBJECTIVE: To describe the incidence of euthanasia and assisted suicide in family practice in the Netherlands, the reasons for its practice, and the characteristics of patients and physicians involved. DESIGN: Cross-sectional survey of a random sample of Dutch family physicians. SETTING: General practices in The Netherlands. PARTICIPANTS: An anonymous questionnaire was mailed to 1042 general practitioners. Of the 996 eligible physicians, 667 (67%) completed the questionnaire. MAIN OUTCOME MEASURES: Reported practices and beliefs concerning euthanasia and assisted suicide. RESULTS: In the course of an average year, 24% of Dutch family physicians had practised euthanasia or assisted suicide. Most deaths took place at home in the presence of others. According to the physicians, the most important reasons for the request were futile suffering, fear or avoidance of loss of dignity, and unbearable suffering. Euthanasia or assisted suicide was mostly (85%) administered to patients with malignant neoplasms. Physicians were more opposed to euthanasia and assisted suicide if they had never practised it, if they had a religious affiliation, and if they were older. CONCLUSIONS: This study presents empiric data about euthanasia and assisted suicide in the context of a permissive euthanasia policy. Understanding Dutch practices could be helpful for Canadians. However, each country needs to resolve these issues in its own way.
PMCID: PMC2255221  PMID: 9040910
12.  Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases 
Objectives To estimate the rate of reporting of euthanasia cases to the Federal Control and Evaluation Committee and to compare the characteristics of reported and unreported cases of euthanasia.
Design Cross sectional analysis.
Setting Flanders, Belgium.
Participants A stratified at random sample was drawn of people who died between 1 June 2007 and 30 November 2007. The certifying physician of each death was sent a questionnaire on end of life decision making in the death concerned.
Main outcome measures The rate of euthanasia cases reported to the Federal Control and Evaluation Committee; physicians’ reasons for not reporting cases of euthanasia; the relation between reporting and non-reporting and the characteristics of the physician and patient; the time by which life was shortened according to the physician; the labelling of the end of life decision by the physician involved; and differences in characteristics of due care between reported and unreported euthanasia cases.
Results The survey response rate was 58.4% (3623/6202 eligible cases). The estimated total number of cases of euthanasia in Flanders in 2007 was 1040 (95% CI 970 to 1109), thus the incidence of euthanasia was estimated as 1.9% of all deaths (95% CI 1.6% to 2.3%). Approximately half (549/1040 (52.8%, 95% CI 43.9% to 60.5%)) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. Physicians who perceived their case as euthanasia reported it in 93.1% (67/72) of cases. Cases of euthanasia were reported less often when the time by which life was shortened was less than one week compared with when the perceived life shortening was greater (37.3% v 74.1%; P<0.001). Unreported cases were generally dealt with less carefully than reported cases: a written request for euthanasia was more often absent (87.7% v 17.6% verbal request only; P<0.001), other physicians and caregivers specialised in palliative care were consulted less often (54.6% v 97.5%; 33.0% v 63.9%; P<0.001 for both), the life ending act was more often performed with opioids or sedatives (92.1% v 4.4%; P<0.001), and the drugs were more often administered by a nurse (41.3% v 0.0%; P<0.001).
Conclusions One out of two euthanasia cases is reported to the Federal Control and Evaluation Committee. Most non-reporting physicians do not perceive their act as euthanasia. Countries debating legalisation of euthanasia should simultaneously consider developing a policy facilitating the due care and reporting obligations of physicians.
doi:10.1136/bmj.c5174
PMCID: PMC2950259  PMID: 20923842
13.  Euthanasia in The Netherlands. 
BMJ : British Medical Journal  1994;308(6940):1346-1349.
The practice of euthanasia in the Netherlands is often used as an argument in debates outside the Netherlands--hence a clear description of the Dutch situation is important. This article summarises recent data and discusses conceptual issues and relevant characteristics of the system of health care. Special emphasis is put on regulation, including relevant data on notification and prosecution. Besides the practice of euthanasia the Dutch are confronted with the gaps in reporting of cases to the public prosecutor and the existence of cases of ending a life without an explicit request. Nevertheless, the "Dutch experiment" need not inevitably lead down the slippery slope because of the visibility and openness of this part of medical practice. This will lead to increased awareness, more safeguards, and improvement of medical decisions concerning the end of life.
PMCID: PMC2540255  PMID: 8019226
14.  Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls 
Current Oncology  2011;18(2):e38-e45.
Euthanasia or assisted suicide—and sometimes both—have been legalized in a small number of countries and states. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Prevention measures have included, among others, explicit consent by the person requesting euthanasia, mandatory reporting of all cases, administration only by physicians (with the exception of Switzerland), and consultation by a second physician.
The present paper provides evidence that these laws and safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. For example, about 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported. Increased tolerance of transgressions in societies with such laws represents a social “slippery slope,” as do changes to the laws and criteria that followed legalization. Although the initial intent was to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children, and people with dementia. A terminal illness is no longer a prerequisite. In the Netherlands, euthanasia for anyone over the age of 70 who is “tired of living” is now being considered. Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide controls and safeguards.
PMCID: PMC3070710  PMID: 21505588
Euthanasia; physician-assisted suicide
15.  Physician-assisted Suicide and Euthanasia in Indian Context: Sooner or Later the Need to Ponder! 
Physician-assisted suicide (PAS) is a controversial subject which has recently captured the interest of media, public, politicians, and medical profession. Although active euthanasia and PAS are illegal in most parts of the world, with the exception of Switzerland and the Netherlands, there is pressure from some politicians and patient support groups to legalize this practice in and around Europe that could possibly affect many parts of the world. The legal status of PAS and euthanasia in India lies in the Indian Penal Code, which deals with the issues of euthanasia, both active and passive, and also PAS. According to Penal Code 1860, active euthanasia is an offence under Section 302 (punishment for murder) or at least under Section 304 (punishment for culpable homicide not amounting to murder). The difference between euthanasia and physician assisted death lies in who administers the lethal dose; in euthanasia, this is done by a doctor or by a third person, whereas in physician-assisted death, this is done by the patient himself. Various religions and their aspects on suicide, PAS, and euthanasia are discussed. People argue that hospitals do not pay attention to patients’ wishes, especially when they are suffering from terminally ill, crippling, and non-responding medical conditions. This is bound to change with the new laws, which might be implemented if PAS is legalized. This issue is becoming relevant to psychiatrists as they need to deal with mental capacity issues all the time.
doi:10.4103/0253-7176.112220
PMCID: PMC3701348  PMID: 23833354
Culture; euthanasia; India; physician-assisted suicide; religion
16.  The Dutch experience with euthanasia: lessons for Canada? 
Anne Mullens used a recent fellowship provided by the Atkinson Foundation to take an in-depth look at euthanasia in the Netherlands. During her time in Holland, she discussed the issue with doctors who support and oppose euthanasia. She accompanied a doctor as he visited a patient who was dying of cancer and was beginning to consider the possibility of euthanasia. She talked to a nonphysician who is adamantly opposed to euthanasia and carries a card stating that. She visited a hospital in Amsterdam that has received requests from foreigners seeking euthansia. Mullens offers a comprehensive look at an issue that continues to provoke strong feelings among Canadian physicians and patients.
Images
PMCID: PMC1337991  PMID: 7773901
17.  Survey of euthanasia practices in animal shelters in Canada 
Questionnaires on methods of euthanasia used in Canadian animal shelters were sent to 196 Canadian animal shelters yielding 67 responses. Sodium pentobarbital injection was the only method of euthanasia used by 61% of establishments that euthanized dogs and 53% of the establishments that euthanized cats. Many of these establishments used pre-medication. Sodium pentobarbital was mostly administered intravenously but some establishments also used intracardiac and intraperitoneal routes, and some only used intracardiac administration for cats. T-61 injection was the only method of euthanasia used by 23% of the establishments that euthanized dogs and 35% of the establishments that euthanized cats. All of these establishments used pre-medication, but the percentages of establishments that only used the intravenous route for administration of T-61 in dogs and cats were 45% and 7%, respectively. Further studies on the use of T-61, and the training and provision of counselling services for staff are recommended.
PMCID: PMC3003577  PMID: 21461208
18.  Euthanasia in Holland: an ethical critique of the new law. 
Journal of Medical Ethics  1994;20(4):212-217.
In the Netherlands the government's proposal for the legal regulation of euthanasia, assisted suicide and the termination of a patient's life without request has been approved by Parliament. The defence of this proposal is to a large extent based on a specific interpretation of data about the practice of euthanasia in that country, published in 1991 (the Remmelink Report). This paper discusses both the interpretation of the data and the new law. On the basis of that and other data, the author concludes that many cases of euthanasia, assisted suicide and termination of a patient's life without request remain unnotified and therefore unreviewed by the legal authorities. It is argued that the new law will not guarantee an improvement to this situation. In short, the new law will not protect effectively the lives of patients, and must, therefore, be open to ethical and legal objection.
PMCID: PMC1376557  PMID: 7861425
19.  Attitudes towards euthanasia. 
Journal of Medical Ethics  1977;3(1):18-25.
There are an infinite variety of attitudes to euthanasia, each individual response to the concept being influenced by many factors. Consequently there is a literature on the subject ranging from the popular article to papers in specialized journals. This study, however, has taken a well defined sample of people, inviting them to answer a questionnaire which was designed to elicit their attitudes to euthanasia in a way which could be analysed statistically. Nor surprisingly attitudes appeared to 'harden' as those answering the questionnaire grew more experienced in dealing with patients and also more professionally established. Thus it was found that of the seven groups questioned practising physicians showed more positive attitudes to euthanasia and their responses did not differ significantly from those of senior medical students. It is these groups which actually or potentially have to resolve the clinical dilemma posed by the dying patient.
PMCID: PMC1154540  PMID: 859163
20.  GPs' views on changing the law on physician-assisted suicide and euthanasia, and willingness to prescribe or inject lethal drugs: a survey from Wales 
If physician-assisted suicide/euthanasia is legalised in the UK, this may be the work of GPs. In the absence of recent or comprehensive evidence about GPs' views on either legalisation or willingness to take part, a questionnaire survey of all Welsh GPs was conducted of whom 1202 (65%) responded. Seven hundred and fifty (62.4% of responders) and 671 (55.8% of responders) said that they did not favour a change in the law to allow physician-assisted suicide/voluntary euthanasia respectively. These data provide a rational basis for determining the position of primary care on this contentious issue.
PMCID: PMC1839020  PMID: 16762127
euthanasia; general practice; physician-assisted suicide
21.  Neonatal euthanasia: A claim for an immoral law 
Clinical Ethics  2013;8(2-3):75-84.
Active ending of the life of a newborn baby is a crime. Yet its clandestine practise is a reality in several European countries. In this paper, we defend the necessity to institute a proper legal frame for what we define as active neonatal euthanasia. The only legal attempt so far, the Dutch Groningen protocol, is not satisfactory. We critically analyse this protocol, as well as several other clinical practises and philosophical stances. Furthermore, we have tried to integrate our opinions as clinicians into a law project, with the purpose of pinpointing several issues, specific of perinatality that should be addressed by such a law. In conclusion, we argue that the legalisation of neonatal euthanasia under exceptional circumstances is the only way to avoid all the “well-intentioned” malpractices associated with ending life at the very dawn of it.
doi:10.1177/1477750913499494
PMCID: PMC3778983  PMID: 24068880
Neonatal active euthanasia; Groningen protocol; postnatal abortion; decision making
22.  Conditions required for a law on active voluntary euthanasia: a survey of nurses' opinions in the Australian Capital Territory. 
Journal of Medical Ethics  1999;25(1):25-30.
OBJECTIVES: To ascertain which conditions nurses believe should be in a law allowing active voluntary euthanasia (AVE). DESIGN: Survey questionnaire posted to registered nurses (RNs). SETTING: Australian Capital Territory (ACT) at the end of 1996, when active voluntary euthanasia was legal in the Northern Territory. SURVEY SAMPLE: A random sample of 2,000 RNs, representing 54 per cent of the RN population in the ACT. MAIN MEASURES: Two methods were used to look at nurses' opinions. The first involved four vignettes which varied in terms of critical characteristics of each patient who was requesting help to die. The respondents were asked if the law should be changed to allow any of these requests. There was also a checklist of conditions, most of which have commonly been included in Australian proposed laws on AVE. The respondents chose those which they believed should apply in a law on AVE. RESULTS: The response rate was 61%. Support for a change in the law to allow AVE was 38% for a young man with AIDS, 39% for an elderly man with early stage Alzheimer's disease, 44% for a young woman who had become quadriplegic and 71% for a middle-aged woman with metastases from breast cancer. The conditions most strongly supported in any future AVE law were: "second doctor's opinion", "cooling off period", "unbearable protracted suffering", "patient fully informed about illness and treatment" and "terminally ill". There was only minority support for "not suffering from treatable depression", "administer the fatal dose themselves" and "over a certain age". CONCLUSION: Given the lack of support for some conditions included in proposed AVE laws, there needs to be further debate about the conditions required in any future AVE bills.
PMCID: PMC479164  PMID: 10070635
23.  Euthanasia and other end of life decisions and care provided in final three months of life: nationwide retrospective study in Belgium 
Objective To explore the relation between the care provided in the final three months of life and the prevalence and types of end of life decisions in Belgium.
Design Two year nationwide retrospective study, 2005-6 (SENTI-MELC study).
Setting Data collection via the sentinel network of general practitioners, an epidemiological surveillance system representative of all general practitioners in Belgium.
Subjects 1690 non-sudden deaths in practices of the sentinel general practitioners.
Main outcome measures Non-sudden deaths of patients (aged >1 year) reported each week. Reported care provided in the final three months of life and the end of life decisions made. Multivariable regression analysis controlled for age, sex, cause, and place of death.
Results Use of specialist multidisciplinary palliative care services was associated with intensified alleviation of symptoms (odds ratio 2.1, 95% confidence interval 1.6 to 2.6), continuous deep sedation forgoing food/fluid (2.9, 1.7 to 4.9), and the total of decisions explicitly intended to shorten life (1.5, 1.1 to 2.1) but not with euthanasia or physician assisted suicide in particular. To a large extent receiving spiritual care was associated with higher frequencies of euthanasia or physician assisted suicide than receiving little spiritual care (18.5, 2.0 to 172.7).
Conclusions End of life decisions that shorten life, including euthanasia or physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care.
doi:10.1136/bmj.b2772
PMCID: PMC2719064  PMID: 19643825
24.  Hospital hygiene in an age of Diagnostic Related Groups (DRG), Protection against Infection Act (IfSG), Book V of the German Code of Social Law (SGB V) and administrative reforms – facts and visions from Bavaria 
Since 1 January 2001, German hospitals and establishments engaged in outpatient surgery are obliged to continually record and evaluate nosocomial infections and the emergence of nosocomial pathogens showing special resistance and multi-resistance profiles. A survey conducted among 164 hospitals revealed that 79 % of establishments already carried out separate surveillance and evaluation of postoperative wound infections, while 77 % also recorded nosocomial infections and 91 % recorded pathogens with special resistance and multi-resistance profiles. However, only the larger hospitals had their own in-house infection control physician, while the smaller establishments generally consulted external infection control physicians. When asked how long such experts made their services available to the hospitals, no clear answer was given. Furthermore, only two-thirds of hospitals had their own infection control nurses (most of whom worked part time). These findings have induced the State Office for Health and Food Safety (LGL) in Bavaria to expand its advisory and information services and to formulate standards in consultation with partners at state level.
The public health offices are legally obliged to supervise infection control policies in hospitals and medical establishments. These supervisory activities have not always been conducted in a uniform manner, thus engendering anxiety among the institutions to be supervised when it comes to discharging their prescribed duties. A concept devised to improve and standardize the monitoring of hospital hygiene is to be used to standardize supervision of infection control practices (by the statutory authorities). With the incorporation of the, hitherto, State Office for Occupational Safety, Occupational Medicine and Safety Engineering into the LGL, the specialist centers for public health and the Trade Supervisory Office will be united under one umbrella. The idea is to avail of the resulting improved cooperation possibilities, so as to avoid duplication of effort as regards the overlapping areas of medical and trade supervision and limit contradictory commentaries and avoid a situation whereby several public health officials have to pay visits to the various establishments. This will also reinforce partnerships between medical establishments and the public health authorities at local level. Some thirty years ago, while the present author could possibly dream of such an outcome when he took his first steps into the, at times arduous, terrain of hospital hygiene, he probably would not have dared to express it.
PMCID: PMC2831495  PMID: 20200676
25.  Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU 
Journal of Medical Ethics  2007;33(6):320-324.
Background
Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services.
Objective
To describe physicians' expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit (ICU).
Design
Mailed survey.
Participants
Physicians responsible for the care of at least 10 patients in ICU over a 6‐month period at a 921‐bed private teaching hospital with an established ethics consultation service. 69 of 92 (75%) eligible physicians responded.
Measurements
Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal‐training programmes for ethics consultants.
Results
Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law (p<0.03), religious traditions (p<0.001), medicine (p<0.001) and conflict‐mediation techniques (p<0.001). When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important.
Conclusions
Although many physicians caring for patients in ICU believe ethics consultants must possess non‐medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a “medicine plus one” view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established.
doi:10.1136/jme.2006.016287
PMCID: PMC2598279  PMID: 17526680

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