Biomedical ethics

Family members do not have an official position in the practice of euthanasia and
physician assisted suicide (EAS) in the Netherlands according to statutory regulations
and related guidelines. However, recent empirical findings on the influence of family
members on EAS decision-making raise practical and ethical questions. Therefore, the
aim of this review is to explore how family members are involved in the Dutch
practice of EAS according to empirical research, and to map out themes that could
serve as a starting point for further empirical and ethical inquiry.

Methods

A systematic mixed studies review was performed. The databases Pubmed, Embase,
PsycInfo, and Emcare were searched to identify empirical studies describing any
aspect of the involvement of family members before, during and after EAS in the
Netherlands from 1980 till 2018. Thematic analysis was chosen as method to
synthesize the quantitative and qualitative studies.

Results

Sixty-six studies were identified. Only 14 studies had family members themselves as
study participants. Four themes emerged from the thematic analysis. 1) Family-related
reasons (not) to request EAS. 2) Roles and responsibilities of family members during
EAS decision-making and performance. 3) Families’ experiences and grief after EAS.
4) Family and ‘the good euthanasia death’ according to Dutch physicians.

Conclusion

Family members seem to be active participants in EAS decision-making, which goes

hand in hand with ambivalent feelings and experiences. Considerations about family
members and the social context appear to be very important for patients and
physicians when they request or grant a request for EAS. Although further empirical
research is needed to assess the depth and generalizability of the results, this review
provides a new perspective on EAS decision-making and challenges the Dutch
ethical-legal framework of EAS. Euthanasia decision-making is typically framed in
the patient-physician dyad, while a patient-physician-family triad seems more
appropriate to describe what happens in clinical practice. This perspective raises
questions about the interpretation of autonomy, the origins of suffering underlying
requests for EAS, and the responsibilities of physicians during EAS decision-making
 Medical ethics: four principles plus attention to scope
The “four principles plus scope” approach provides a simple, accessible, and culturally
neutral approach to thinking about ethical issues in health care. The approach, developed in
the United States, is based on four common, basic prima facie moral commitments - respect
for autonomy, beneficence, non-maleficence, and justice - plus concern for their scope of
application. It offers a common, basic moral analytical framework and a common, basic
moral language. Although they do not provide ordered rules, these principles can help doctors
and other health care workers to make decisions when reflecting on moral issues that arise at
work.

Nine years ago the BMJ allowed me to introduce to its readers1 an approach to medical ethics
developed by the Americans Beauchamp and Childress,2 which is based on four prima facie
moral principles and attention to these principles' scope of application. Since then I have
often been asked for a summary of this approach by doctors and other health care workers
who find it helpful for organising their thoughts about medical ethics. This paper, based on
the preface of a large multiauthor textbook on medical ethics,3 offers a brief account of this
“four principles plus scope” approach.
The four principles plus scope approach claims that whatever our personal philosophy,
politics, religion, moral theory, or life stance, we will find no difficulty in committing
ourselves to four prima facie moral principles plus a reflective concern about their scope of
application. Moreover, these four principles, plus attention to their scope of application,
encompass most of the moral issues that arise in health care.

The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and
justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that
the principle is binding unless it conflicts with another moral principle …