Non-treatment decisions on grounds of "medical futility" and "quality of life": interviews with fourteen Dutch neonatologists

This essay opens with background information about the concept of "medical futility" and the regulation of nontreatment decisions in Dutch neonatology. The regulations include a list of criteria for predicting the baby's future quality of life. The second part presents the findings from interviews with fourteen Dutch neonatologists on the mannerin which they apply the criteria in their practice.     

End-of-life decisions in Italy: an overview of the current situation

This contribution analyzes end-of-life decisions in Italy. Its aim is to report the complex situation in end-of-life decisions. The scientific work applies an interdisciplinary approach by taking into consideration the position of the medical and biomedical communities. In addition, it examines the perspective of the jurisprudence and of the parliament. The investigation of all these parties is fundamental since Italy is one of the few Western European countries that does not have an ad hoc law ruling advance directives. After a complete and comprehensive study of the standpoint taken by the medical and biomedical communities, in addition to the position taken by the Italian law-maker, this contribution underlines the significance of the role of the jurisprudence. In the conclusions, the author underlines the significance of a specific law governing advance directives since it will end the contrasts between these different communities in addition to provide legal certainty.     

End-of-Life Decisions in Albania: The Call for an Ethical Revision

Liverpool Law Review - While in Western European countries, the end-of-life decisions have become a matter of public policy, this paper provides a detailed analysis of end-of-life decisions in...     

How do disciplinary tribunals evaluate the "gut feelings" of doctors? An analysis of Dutch tribunal decisions, 2000-2008

A sense of alarm, which is a form of "gut feeling" sometimes plays a part in the decisions of medical disciplinary tribunals in The Netherlands. Since these judgments are regarded as setting standards for professional attitudes in The Netherlands, the question arises how Dutch tribunals have evaluated gut feelings, and how tribunals in other European countries deal with them. An exploratory study searched two Dutch digital databases (2000-2008) and asked 26 national representatives of the European General Practice Research Network for information about the role of gut feelings in tribunals' decisions. A sense of alarm was mentioned in judgments in 34 Dutch cases. Defendants were hardly ever reproached for missing the correct diagnosis, but mostly for not acting in a professional manner. The sense of alarm was referred to as a diagnostic tool to assess a patient's situation, although the judgments indicate that it must be followed by further diagnostic steps. The role of gut feelings in decisions of disciplinary tribunals in Europe is unclear. The authors conclude that the sense of alarm as a diagnostic tool has been taken seriously by Dutch tribunals. Its timely development is considered to be an element of the professional standards for doctors.     

Acronyms of dying versus patient autonomy

In medical practice in Germany and several other countries abbreviated orders linked to end-of-life decisions, such as DNR (do not resuscitate), are increasingly used. In order to investigate their legal status, this article gives an overview of the recently passed German law, which regulates the process of end-of-life decision-making and the use of living wills, giving primacy to patient autonomy. Concerning the risk of misinterpretation of acronyms, the article describes the impacts of such orders on patient autonomy and safety and suggests a clear systematic classification of the different DNR orders in order to investigate their legal status under the German law. Their general binding force is to be acknowledged, depending on its origination and the fulfilment of certain requirements.     

Roman concept of mental capacity to make end-of-life decisions

When assessing decisional competence of patients, psychiatrists have to balance the patients' right to personal autonomy, their condition and wishes against principles of medical ethics and professional discretion. This article explores the age-old legal and ethical dilemmas posed by refusal of vital medical treatment by patients and their mental capacity to make end-of-life decisions against the background of philosophical, legal and medical approaches to these issues in the time of the Younger Pliny (c62-c113 CE). Classical Roman discourse regarding mental competency and "voluntary death" formed an important theme of the vast corpus of Greco-Roman writings, which was moulded not only by legal permissibility of suicide but also by philosophical (in modern terms, moral or ethical) considerations. Indeed, the legal and ethical issues of evaluating the acceptability of end of life decisions discussed in the Letters are as pertinent today as they were 2000 years ago. We may gain valuable insights about our own methodologies and frames of reference in this area of the law and psychiatry by examining Classical Roman approaches to evaluating acceptability of death-choices as described in Pliny's Letters and the writings of some of his peers.     

Parents as decision-makers--do the attitudes of Norwegian doctors conform to law?

This article studies whether the attitudes of Norwegian doctors regarding surrogate decision power in end-of-life care conform to legal rules, particularly as they apply to the protection of children. The article is based on a hypothetical scenario concerning a critically ill child, believed to be dying, presented to 406 doctors. The study indicates that doctors may permit parental/surrogate decision-making to a greater extent than justified by law, sometimes in contravention of the child's best interests, which should be a fundamental guideline in all decisions that concern children. This article suggests a need to improve knowledge of doctors concerning parents'/surrogates' right to participate in life-or-death decisions. We conclude that Norway needs a precedent decision from the Supreme Court that confirms the right of judicial review of end-of-life decisions, and which applies the principle of the child's best interests as a fundamental guideline in the final decision.     

Capacity and medical self-determination in Australia

The expansion of patients' rights and the increasing complexity of the science of medicine raises serious legal and social questions, particularly when they pertain to end-of-life decision-making. Medical science continues to find ways of maintaining or extending life in a body or mind affected by disease or trauma and regular advances in medical technology and practice mean that the natural course of illness or injury will rarely be uninterrupted by some form of medical intervention. This progressive "medicalisation" of death, together with enhanced patient autonomy, means that choices can increasingly be made regarding medical treatment which may ultimately influence both the time and the way in which a person dies. This article examines both legislation and the common law in Australia particularly as it pertains to medical decision-making at end-of-life and the patient's right of self-determination.     

The Israeli Patient's Rights Law: evidence for deprofessionalization?

In this paper, the Israeli Patient's Rights Law of 1996 is discussed within the framework of Haug's predicted process of deprofessionalization. It is argued that the law reflects global processes such as the diffusion of knowledge, consumerism, and values that emphasize human rights and democracy. By guaranteeing patients' access to medical information, by submitting medical decisions to extra-professional regulation, the law erodes professional power.     

The Dutch experience

Euthanasia has been legally sanctioned in the Netherlands by a series of court decisions going back to the 1970s. The author discusses the cultural and historical factors that may have contributed to this development. In the past decade, studies sanctioned by the Dutch government reveal that guidelines established for the regulation of euthanasia--a voluntary, well-considered, persistent request, intolerable suffering that cannot be relieved, consultation with a colleague, and reporting of cases--are consistently violated. Of greatest concern is the number of patients who are put to death without their consent--there are more involuntary than voluntary cases. Euthanasia intended originally for the exceptional case has become an accepted way of dealing with the physical and mental distress of serious or terminal illness. In the process palliative care has become one of the casualties while hospice care lags behind that of other countries. Case examples are given.     

The Best Interests Standard for Incompetent or Incapacitated Persons of All Ages

When making decisions for adults who lack decision-making capacity and have no discernable preferences, widespread support exists for using the Best Interests Standard. This policy appeals to adults and is compatible with many important recommendations for persons facing end-of-life choices.Common objections to the policy are discussed as well as different meanings of this Standard identified, such as using it to express goals or ideals and to make practical decisions incorporating what reasonable persons would want. For reasons of consistency, fairness, and compassion, this standard should be used for all incapacitated persons.     

The Dutch Euthanasia Act and related issues

In 2002 the Dutch Euthanasia Act came into force. This Act is the result of a lengthy developmental process. It codifies the requirements that have evolved in case law and medical ethics since 1973. Empirical data indicate that the Dutch euthanasia practice is stabilising. Euthanasia and assisted suicide occur in 2.7% of all deaths. Now that the Act has been passed, the focus is on improving the quality of medical decision-making. From an international perspective, the Dutch legislation is exceptional. However, it appears that other countries and international organisations are considering euthanasia legislation as well. It remains to be seen how influential the Dutch model will prove to be.     

The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation.

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is designed to improve end-of-life care by converting patients' treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. An observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and long-term care organizations/agencies in combination with a review of relevant state law.     

The right to be forgotten – a Dutch perspective

This paper will be investigate to what extent the right to be forgotten as proposed by the European Commission is already recognized in Dutch tort law. The focus of this paper will be on the existence and the desirability of such a right and not on questions of enforcement. It is submitted that although Dutch law does not recognize the right to be forgotten as such, several judicial decisions can be identified that afford protection to interests that are also protected by the proposed right to be forgotten. This indicates that in the Netherlands a right to be forgotten in some form or another might have developed over time but this would have been a lengthy affair. A more precise formulation of this right by the legislator is therefore welcomed. It has been remarked that the name ‘right to be forgotten’ may give rise to unrealistic expectations but the Dutch experience shows that people do not seem to be very aware of their rights. ‘A right to be forgotten’ – however imprecise from a legal viewpoint – might be catchy enough to remedy this.     

欧洲法律下的提单管辖权条款

本文通过对荷兰法律及有关管辖权和民商事判决执行方面的两个主要公约 (EEX公约和 L ugano公约 )的介绍 ,结合大量的案例和欧共体法院对公约的解释 ,论述了欧洲法律下一个有效的标准格式中的管辖权条款所包含的条件及公约和各国国内法对当事人自由订立的标准格式中的管辖权条款的限制。     

Recent developments in health law in the Netherlands

This article gives a few examples of recent developments in Dutch health law, namely equal access to health care, compulsory placement and treatment in a psychiatric hospital, and end of life decisions. They are outstanding examples of trends in health legislation that require to be followed closely.     

Mental competence and end-of-life decision making: death row volunteering and euthanasia

This article reports on a qualitative study of defense attorneys' perceptions of the mental competence or rationality of death row inmates' decisions to waive habeas appeals and proceed directly to execution. Interviews were conducted with twenty attorneys who have either directly represented or been closely involved with would-be volunteers. Through analytic comparison with another end-of-life decision, euthanasia, this article reports on four themes from the interviews: (a) attorneys' perceptions of the legal standard of competence, (b) their perceptions of the competency evaluation process, (c) implications of competing interpretive frames (i.e., volunteering vs. suicide), and (d) the rationality of decisions to waive appeals. Implications of research findings, particularly in terms of recent restructured models of competence, are also discussed.     

Forensic medicine in The Netherlands

In this paper a review is given of the evolution of the Dutch Forensic Medical Association (Forensisch Medisch Genootschap, FMG): post-graduate education and the position of the police surgeon today in the Dutch legal and medical society. In just a couple of years forensic medicine has grown into a respected form of social health with worldwide contacts.     

The semblance of autonomy: treatment of persons with disabilities under the Uniform Health-Care Decisions Act

This Article illuminates the dangers of the Uniform Health-Care Decisions Act, which provides a set of model rules designed to clarify and expedite end-of-life health-care decisionmaking for incapacitated patients. The uniform commissioners and many scholars who have commented on the Act have touted the legislation as a model for defending patient autonomy. As this Article will reveal, the impression of autonomy is an illusion. In fact, the Act privileges the perspectives of the able-bodied over those of persons with disabilities, endangers the autonomy of incapacitated patients, and empowers proxy decisionmakers who have incentives to terminate treatment. These risks have become all the more significant with the rise of managed-care programs that create pressures to minimize care. After highlighting the serious risks to vulnerable patients under the Uniform Health-Care Decisions Act, the Article offers alternative rules and stronger safeguards to better protect patient autonomy and defend against wrongful health-care decisions. This Article urges states seeking improved end-of-life health-care procedures to codify these or similar protections in order to avoid the lethal shortcomings of the Uniform Health-Care Decisions Act.     

Hospital policy in The Netherlands: the parameters of structural stalemate

The Dutch hospital sector has recently been the subject of two divergent national policy initiatives. Following a mixed experience with regulation in the mid-1980s, the national government has now taken the first steps in a radical shift toward market-based competition. This article suggests that neither official strategy can address the fundamental structural and cultural factors that shape institutional behavior in the Dutch hospital system. Drawing upon empirical evidence from two 1987 hospital case studies, this article contends that Dutch hospital management reflects a precentralized insularity which, in turn, sharply reduces the likelihood that either publicly or privately framed decentralized strategies can be successfully implemented.