Biomedical subjects
Publications and source records attributed to P Schotsmans.
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.
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The Belgian health care system has a few features that may have contributed to the rising costs of health care: patients' free choice of physicians, large clinical freedom of physicians, essentially a fee-for-service remuneration for medical specialists in which the fees are agreed between insurance funds and physicians. The increased medical consumption and costs have prompted the state and insurance companies to take measures that limit the professional autonomy of the physicians. Access to medical education, free until 1997, is now restricted. The medical profession is organized in the Order of Physicians that has established a code of professional ethics that has moral but not legal force. So far, there is no special legislation for the patient-physician relationship, though laws on specitic issues like organ transplantation contain duties for physicians. In recent years a debate is taking place on patients' rights, of which informed consent is central and gaining importance in medico-legal publications. An analysis of (ethical and legal) regulations concerning the withholding or withdrawal of treatment by physicians demonstrate that the profession still enjoys a large clinical autonomy, though due discussion with the patient has become more explicitly required. The respect for professional autonomy is not primarily due to any formal power that the Order of Physicians would have, but is rather grounded in the generally high quality of the patient-physician relationship that in ethical terms is considered essentially as a confidence relationship rather than a contractual relationship.
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BACKGROUND: The best care and management of patients in persistent vegetative state (PVS) has been the subject of sustained moral and legal debate for a number of years. However, the views of specialist doctors in Belgium involved in the care for patients in PVS are largely unknown. METHODS: A postal questionnaire was sent to 403 members of Belgian Societies of Neurosurgeons, Neurologists and Rehabilitation Doctors. Their views were sought on various aspects of the management and care of PVS, focusing on the issue of the appropriateness of non-treatment and the withdrawal of artificial feeding. FINDINGS: Of the 208 doctors who completed the questionnaires (52%), 172 (83%) indicated that they had been involved in the management of a patient in PVS. 88% of the responding doctors thought it was sometimes appropriate not to treat acute infections or other life-threatening conditions in a PVS patient. Fifty-six percent considered it sometimes appropriate to withdraw artificial feeding. About three-quarter of physicians who considered both treatment-limiting decisions appropriate thought that such decisions could be considered within the first year of the patient being in PVS. Forty percent accorded a decisive influence to an advance directive and only a small number of doctors considered the influence of the patient's family in the decision to withdraw artificial feeding as decisive. Over 80% of the clinicians disagreed with the view that each decision about withdrawing artificial nutrition and hydration (ANH) should come before the courts. INTERPRETATION: Doctors in Belgium seem to be more reluctant to withdraw artificial feeding than not to treat acute infections or other life-threatening conditions in PVS. The reason for this difference appeared to be connected with the moral as well as with the clinical content of the decision. The broad variety of answers on the interval when the vegetative state is to be regarded as permanent and when treatment-limiting decisions are appropriate, could be due to the lack of official guidelines in Belgium. There seems however to be no consensus about a future policy in Belgium for making decisions about the withdrawal of ANH.
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