We study the connection between factors of the Medvedev lattice and constructive logic. The algebraic properties of these factors determine logics lying in between intuitionistic propositional logic and the logic of the weak law of the excluded middle (also known as De Morgan, or Jankov, logic). We discuss the relation between the weak law of the excluded middle and the algebraic notion of join-reducibility. Finally we discuss autoreducible degrees.

This book is the first part of a comprehensive study of Wittgenstein's conception of language description. Describing language was no pastime occupation for the philosopher. It was hard work and it meant struggle. It made for a philosophy that required Wittgenstein's full attention and half his life. His approach had always been working on himself, on how he saw things. The central claim of this book is that nothing will come of our exegetical efforts to see what Wittgenstein's later philosophy (...) amounts to if his work on describing language is not given the place and concern it deserves. The book shows what his philosophy might begin to look like in the light of critical questions around his interest to see the end of the day with descriptions, and these things only. (shrink)

We investigate the structure of the Medvedev lattice as a partial order. We prove that every interval in the lattice is either finite, in which case it is isomorphic to a finite Boolean algebra, or contains an antichain of size $2^{2^{\aleph }0}$ , the size of the lattice itself. We also prove that it is consistent with ZFC that the lattice has chains of size $2^{2^{\aleph }0}$ , and in fact these big chains occur in every infinite interval. We also (...) study embeddings of lattices and algebras. We show that large Boolean algebras can be embedded into the Medvedev lattice as upper semilattices, but that a Boolean algebra can be embedded as a lattice only if it is countable. Finally we discuss which of these results hold for the closely related Muchnik lattice. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

ABSTRACT In the work of Ernesto Laclau, populism is treated as a hegemonic challenge. Hegemony describes the usurpation of the image of society as a totality by a particular and underdetermined social imaginary. Seen through the lens of what Johann P. Arnason terms “post-transcendental phenomenology”, this concerns the way in which a society sees and experiences both itself and the world it inhabits. This article suggests that hegemonic social imaginaries are built into a society’s public spaces, and are in turn (...) experienced by citizens moving through these spaces, meaning that the built environment is central to the development of populist imaginaries. The article discusses how the neoliberal city exemplifies the way social imaginaries are inscribed into the physical landscape by highlighting three moments in the city; the institution of a certain imaginary as dominant; its sedimentation within the urban fabric over time; and finally, the re-activation of the original moment of institution, which opens up the possibility for new beginnings to overwrite the imaginaries encoded in the city. These three moments describe how physical, built spaces make concrete the power relations and horizons of possibility of the hegemonic imaginary—making possible and encouraging certain ways of being while discouraging (and hiding) others. This hegemonic logic of occupying a public space in the name of a particular subset of the population is a not only parallel to the form of populist politics, but populist sentiment is—at least in part—provoked by the experiences of inhabiting these spaces. (shrink)

We prove that there are uncountably many sets that are low for the class of Schnorr random reals. We give a purely recursion theoretic characterization of these sets and show that they all have Turing degree incomparable to 0'. This contrasts with a result of Kučera and Terwijn [5] on sets that are low for the class of Martin-Löf random reals.

Introduction: In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. Methods: 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a “standard case” of a patient with physical suffering and limited life expectancy, the descriptions included cases in (...) which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. Results: The cases were recognisable for almost all respondents. For the “standard case” nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2–49%) than consultants (25–79%) and members of the euthanasia review committees (24–88%). In each group, the suffering of patients with early dementia and patients who were “tired of living” was least often considered to be unbearable. Conclusions: When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient’s suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia. (shrink)

BackgroundThe 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.MethodsWe did an electronic search of seven Dutch national newspapers between January 2009 and May 2010 and conducted a content analysis.ResultsOf 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.ConclusionsOf 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. (shrink)

In this study, we examine the influence of senior leadership on firms’ corporate social responsibility. We integrate upper echelons research that has investigated either the influence of the CEO or the top management team on CSR. We contend that functional experience complementarity between CEOs and TMTs in formulating and implementing CSR strategy may underlie differentiated strategies in CSR. We find that when CEOs who have predominant experience in output functions are complemented by TMTs with a lower proportion of members who (...) have experience in output functions, there is a pronounced effect on the community, product, and diversity dimensions of CSR. In turn, when output-oriented CEOs are complemented by output-oriented TMTs, we observe an effect on the employee relations dimension of CSR. Interestingly, we find no influence of CEO-TMT complementarity on the environment dimension of CSR. In general, our empirical results support the relevance of the interaction between CEOs and their TMTs in defining their firms’ CSR profile. (shrink)

Name der Zeitschrift: Wittgenstein-Studien Jahrgang: 5 Heft: 1 Seiten: 57-88.

Simpson introduced the lattice of Π0 1 classes under Medvedev reducibility. Questions regarding completeness in are related to questions about measure and randomness. We present a solution to a question of Simpson about Medvedev degrees of Π0 1 classes of positive measure that was independently solved by Simpson and Slaman. We then proceed to discuss connections to constructive logic. In particular we show that the dual of does not allow an implication operator (i.e. that is not a Heyting algebra). We (...) also discuss properties of the class of PA-complete sets that are relevant in this context. (shrink)

In this study, we examine the influence of senior leadership on firms’ corporate social responsibility. We integrate upper echelons research that has investigated either the influence of the CEO or the top management team on CSR. We contend that functional experience complementarity between CEOs and TMTs in formulating and implementing CSR strategy may underlie differentiated strategies in CSR. We find that when CEOs who have predominant experience in output functions are complemented by TMTs with a lower proportion of members who (...) have experience in output functions, there is a pronounced effect on the community, product, and diversity dimensions of CSR. In turn, when output-oriented CEOs are complemented by output-oriented TMTs, we observe an effect on the employee relations dimension of CSR. Interestingly, we find no influence of CEO-TMT complementarity on the environment dimension of CSR. In general, our empirical results support the relevance of the interaction between CEOs and their TMTs in defining their firms’ CSR profile. (shrink)

Model transfer refers to the observation that particular model structures are used across multiple distinct scientific domains. This paper puts forward an account to explain the inter-domain transfer of model structures. Central in the account is the role of validation criteria in determining whether a model is considered to be useful by practitioners. Validation criteria are points of reference to which model correctness for a particular purpose is assessed. I argue that validation criteria can be categorized as being mathematical, theoretical (...) or phenomenological in nature. Model transfer is explained by overlap in validation criteria between scientific domains. Particular emphasis is placed on overlap between phenomenological criteria. Overlap in phenomenological criteria can be explained through the notion of universal patterns. Universal patterns are abstract structures that can be made to refer to multiple distinct phenomena when coupled with phenomena-specific empirical content. I present the case study of the Yule Process, in which universal patterns play a crucial role in explaining model transfer. This paper provides an account of model transfer that stays close to modelling practice and expands existing accounts by introducing the notion of universal patterns. (shrink)

In the context of his theory of numberings, Ershov showed that Kleene's recursion theorem holds for any precomplete numbering. We discuss various generalizations of this result. Among other things, we show that Arslanov's completeness criterion also holds for every precomplete numbering, and we discuss the relation with Visser's ADN theorem, as well as the uniformity or nonuniformity of the various fixed point theorems. Finally, we base numberings on partial combinatory algebras and prove a generalization of Ershov's theorem in this context.

For every partial combinatory algebra, we define a hierarchy of extensionality relations using ordinals. We investigate the closure ordinals of pca’s, i.e., the smallest ordinals where these relations become equal. We show that the closure ordinal of Kleene’s first model is ${\omega _1^{\textit {CK}}}$ and that the closure ordinal of Kleene’s second model is $\omega _1$. We calculate the exact complexities of the extensionality relations in Kleene’s first model, showing that they exhaust the hyperarithmetical hierarchy. We also discuss embeddings of (...) pca’s. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Background Studies describing physicians’ experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation.Methods Qualitative face-to-face interviews were held in 2007–2008 with 36 physicians , including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses.Results In both countries, the use of sedation (...) was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives.Conclusions The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making. (shrink)

We define a variant of the standard Kripke semantics for intuitionistic logic, motivated by the connection between constructive logic and the Medvedev lattice. We show that while the new semantics is still complete, it gives a simple and direct correspondence between Kripke models and algebraic structures such as factors of the Medvedev lattice.

Context In some cases, physicians estimate that continuous sedation until death may have a life-shortening effect. The accuracy of these estimations can be questioned.Aim The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death.Methods In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach and an (...) indirect approach . The intrarater agreement between both approaches was determined with a weighted κ.Results According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%. The intrarater agreement between both approaches was fair . In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates.Conclusions The results show a discrepancy between different approaches to estimate the potential life-shortening effect of continuous sedation until death. (shrink)

We investigate the initial segments of the Medvedev lattice as Brouwer algebras, and study the propositional logics connected to them.

A positive answer to a question of M. van Lambalgen and D. Zambella whether there exist nonrecursive sets that are low for the class of random sets is obtained. Here a set A is low for the class RAND of random sets if RAND = RAND A.

We develop arithmetical measure theory along the lines of Lutz [10]. This yields the same notion of measure 0 set as considered before by Martin-Löf, Schnorr, and others. We prove that the class of sets constructible by r.e.-constructors, a direct analogue of the classes Lutz devised his resource bounded measures for in [10], is not equal to RE, the class of r.e. sets, and we locate this class exactly in terms of the common recursion-theoretic reducibilities below K. We note that (...) the class of sets that bounded truth-table reduce to K has r.e.-measure 0, and show that this cannot be improved to truth-table. For Δ2-measure the borderline between measure zero and measure nonzero lies between weak truth-table reducibility and Turing reducibility to K. It follows that there exists a Martin-Löf random set that is tt-reducible to K, and that no such set is btt-reducible to K. In fact, by a result of Kautz, a much more general result holds. (shrink)

We prove a number of elementary facts about computability in partial combinatory algebras. We disprove a suggestion made by Kreisel about using Friedberg numberings to construct extensional pca’s. We then discuss separability and elements without total extensions. We relate this to Ershov’s notion of precompleteness, and we show that precomplete numberings are not 1–1 in general.

We discuss the effectivity of Arslanov’s completeness criterion. In particular, we show that a parameterized version, similar to the recursion theorem with parameters, fails. We also discuss the effectivity of another extension of the recursion theorem, namely Visser’s ADN theorem, as well as that of a joint generalization of the ADN theorem and Arslanov’s completeness criterion.

Partial combinatory algebras (pcas) are algebraic structures that serve as generalized models of computation. In this article, we study embeddings of pcas. In particular, we systematize the embeddings between relativizations of Kleene’s models, of van Oosten’s sequential computation model, and of Scott’s graph model, showing that an embedding between two relativized models exists if and only if there exists a particular reduction between the oracles. We obtain a similar result for the lambda calculus, showing in particular that it cannot be (...) embedded in Kleene’s first model. (shrink)

We study the model-theoretic aspects of a probability logic suited for talking about measure spaces. This nonclassical logic has a model theory rather different from that of classical predicate logic. In general, not every satisfiable set of sentences has a countable model, but we show that one can always build a model on the unit interval. Also, the probability logic under consideration is not compact. However, using ultraproducts we can prove a compactness theorem for a certain class of weak models.

We study a class of formulas generalizing the weak law of the excluded middle and provide a characterization of these formulas in terms of Kripke frames and Brouwer algebras. We use these formulas to separate logics corresponding to factors of the Medvedev lattice.

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Can the straight line be analysed mathematically such that it does not fall apart into a set of discrete points, as is usually done but through which its fundamental continuity is lost? And are there objects of pure mathematics that can change through time? Mathematician and philosopher L.E.J. Brouwer argued that the two questions are closely related and that the answer to both is "yes''. To this end he introduced a new kind of object into mathematics, the choice sequence. But (...) other mathematicians and philosophers have been voicing objections to choice sequences from the start. This book aims to provide a sound philosophical basis for Brouwer's choice sequences by subjecting them to a phenomenological critique in the style of the later Husserl. (shrink)

Continuous sedation at the end of life is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may (...) facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this ‘paradigm case’ was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation. (shrink)

We report on some recent work centered on attempts to understand when one set is more random than another. We look at various methods of calibration by initial segment complexity, such as those introduced by Solovay [125], Downey, Hirschfeldt, and Nies [39], Downey, Hirschfeldt, and LaForte [36], and Downey [31]; as well as other methods such as lowness notions of Kučera and Terwijn [71], Terwijn and Zambella [133], Nies [101, 100], and Downey, Griffiths, and Reid [34]; higher level randomness notions (...) going back to the work of Kurtz [73], Kautz [61], and Solovay [125]; and other calibrations of randomness based on definitions along the lines of Schnorr [117].These notions have complex interrelationships, and connections to classical notions from computability theory such as relative computability and enumerability. Computability figures in obvious ways in definitions of effective randomness, but there are also applications of notions related to randomness in computability theory. For instance, an exciting by-product of the program we describe is a more-or-less naturalrequirement-freesolution to Post's Problem, much along the lines of the Dekker deficiency set. (shrink)

The Dutch law states that a physician may perform euthanasia according to a written advance euthanasia directive when a patient is incompetent as long as all legal criteria of due care are met. This may also hold for patients with advanced dementia. We investigated the differing opinions of physicians and members of the general public on the acceptability of euthanasia in patients with advanced dementia.

This article was derived from my doctoral thesis, ‘Post-apartheid racism among Afrikaans speaking urban adolescents: A narrative-pastoral reflection’. The impetus for this study was the seemingly increasing occurrences of racism amongst post-apartheid Afrikaans-speaking urban adolescents in South Africa by taking a narrative practical theological perspective on the matter to help build meaningful cross-cultural dialogue. This study explored the level of dialogue of the participants using a postfoundational paradigm. Two questions guided the investigation: How deeply embedded are objectifying of cross-cultural relationships? (...) How can we instigate honest dialogue aiding us in being more aware of our biases to embrace diversity and going forward as a unity in diversity? This study was conducted in 2016 amongst white Afrikaans-speaking urban adolescents living in Pretoria-East, South Africa. I had four group conversations with my co-researchers, with six to eight adolescents per group. I made use of certain empirical research methods, such as narrative interviewing and group discussions. From an epistemological perspective, a postfoundational, social constructionist perspective, including an auto-ethnographical approach, was followed. The research indicated that Afrikaner adolescents could live life unquestioned from a position of power and objectivity that was culturally inherited. It was found that by objectifying relationships, diverse engagement becomes almost impossible. Consequently, this article advocates for a dialogical approach towards building relationships in a context where people feel vulnerable and shameful, have fears, but also gain trust to contribute to meaningful dialogue with ‘others’. (shrink)

This contribution offers an introduction to the Special Issue 'Rethinking the European Social Market Economy'. It places the Special Issue against the background of the debate on free markets versus social protection in the European Union and the inclusion of the notion of 'social market economy' in the Treaty on European Union. It sketches the meaning and development of the social market economy concept, and introduces the key questions underlying this Special Issue and the contributions included in it.

If is a random sequence, then the sequence is clearly not random; however, seems to be “about half random”. L. Staiger [Kolmogorov complexity and Hausdorff dimension, Inform. and Comput. 103 159–194 and A tight upper bound on Kolmogorov complexity and uniformly optimal prediction, Theory Comput. Syst. 31 215–229] and K. Tadaki [A generalisation of Chaitin’s halting probability Ω and halting self-similar sets, Hokkaido Math. J. 31 219–253] have studied the degree of randomness of sequences or reals by measuring their “degree (...) of compression”. This line of study leads to various definitions of partial randomness. In this paper we explore some relations between these definitions. Among other results we obtain a characterisation of Σ1-dimension in terms of strong Martin-Löf ε-tests , and we show that ε-randomness for ε is different than the classical 1-randomness. (shrink)

Introduction: The Dutch Euthanasia Act states that euthanasia is not punishable if the attending physician acts in accordance with the statutory due care criteria. These criteria hold that: there should be a voluntary and well-considered request, the patient’s suffering should be unbearable and hopeless, the patient should be informed about their situation, there are no reasonable alternatives, an independent physician should be consulted, and the method should be medically and technically appropriate. This study investigates whether physicians experience problems with these (...) criteria in medical practice.Methods: In 2006, questionnaires were sent to a random, stratified sample of 2100 Dutch physicians . Physicians were asked about problems in their decision-making related to requests for euthanasia or assisted suicide after enforcement of the 2002 Euthanasia Act.Results: Of all physicians who had received a request for euthanasia or assisted suicide , 25% had experienced problems in the decision-making with regard to at least one of the criteria of due care. Physicians who had experienced problems mostly indicated to have had problems related to evaluating whether or not the patient’s suffering was unbearable and hopeless and whether or not the patient’s request was voluntary or well considered .Discussion: Physicians in The Netherlands most frequently reported problems related to aspects in which they have to evaluate the patient’s subjective perspective. However, it can be questioned whether placing emphasis on these subjective aspects is an adequate fulfilment of the duties imposed on physicians, as laid down in the Dutch Euthanasia Act. (shrink)

BackgroundAn 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.MethodsWe 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.ResultsPhysicians 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%).ConclusionDutch 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. (shrink)

BackgroundThe COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19.MethodsAn extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. ResultsThree (...) hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect, ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior.ConclusionLevels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care. (shrink)

Cognitive Science, Volume 46, Issue 9, September 2022.