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ガーディアン紙のオランダでの乳幼児安楽死の議論についての解説記事。記事末にはイギリスでの人工呼吸器が必要な11ヶ月の幼児の治療打ち切り問題に関するガーディアン紙記事へのリンクを掲載。
オランダでは自分の意思が表明できるとされる12歳以上には安楽死が認められているが、それより低年齢の者に対しては認められていない。しかし、これまでも秘密に乳幼児安楽死は行われており、安楽死を公表した医者が殺人で起訴されたが無罪になった事例も2つ存在している。その後は18の事例が司法局に報告されるが起訴はされていない。イギリスでは、手当てをしても助からないと医者が判断した場合は鎮痛剤を与えるにとどめて延命治療を施さないケースが一般的だが、オランダのように致死量のモルヒネと鎮痛剤を注射して死を早めるようなことは医療の倫理（のガイドライン）に反するとされ、行われた事例はない。
http://society.guardian.co.uk/health/news/0,8363,1377864,00.html
Secret killings of newborn babies trap Dutch doctors in moral maze
Call for new rules to end dilemma for medical and legal professions
Ian Traynor in Nijmegen, the Netherlands
Tuesday December 21, 2004
The Guardian
Behind the scenes paediatricians in the Netherlands have been making tacit deals with local prosecutors' offices for years, promising to report cases of "life-ending treatment for newborns" in return for guarantees that the doctors will not find themselves hauled into the dock facing charges of murder.
Last year Dr Verhagen's clinic in Groningen carried out three terminations of newborns and reported the cases to the prosecutor's office, which decided not to bring charges.
Leendert De Lange, an official at the national prosecutor's office in The Hague, says there have been 18 such cases of "neo-natal" deaths reported to the judicial authorities in the past four years, none of them resulting in prosecution.
The doctors say this is around one third of the total number of such cases, with most cases going unreported because of the doctors' fears.
Two test cases in the mid-90s set the precedent. Two doctors, one a neurologist, the other a GP, reported the killing of two newborns and were tried for murder. They were acquitted and appeal courts in both cases confirmed the acquittals. Since then there have been no more trials.
"In fact the prosecutors are not prosecuting these cases," says Professor John Griffiths, author of the 1997 book, Euthanasia and Law in The Netherlands, and an expert in euthanasia law at the university of Gronignen, in the north-east of the country.
Such a situation is not good enough for Dr Louis Kollée, the head of paediatrics at the Radboud University Medical Centre in the eastern Dutch town of Nijmegen.
Along with a bunch of likeminded colleagues from children's and maternity wards across the Netherlands, Dr Kollée is campaigning for new rules surrounding the killing at birth of babies whose condition is so serious that they cannot be expected to survive for long.
"If the doctor and the parents decide to terminate the life of the baby, it is illegal, in any country. So it is murder," says Dr Kollée. "This is all very problematic for a doctor. He feels like a criminal. It's very difficult."
Dr Kollée and his colleagues argue that they want neither to legalise nor to decriminalise the lethal injections administered by doctors into newborns. But they want a new system of government-endorsed regulation that will minimise the chances of prosecution.
Professor Griffiths says this is a contradictory position, that the practice can only either be legal or illegal. "And if it's illegal, it can only be murder."
But the paediatrics lobby has taken legal advice and is confident that its campaign can succeed.
A 15-page protocol drafted by the doctors and their lawyers last September calls for government action on their concerns and for the formation of a new national commission to seek a way out of the moral maze.
The increasingly public debate over how to handle such distressing cases - Dr Verhagen gives the example of a newborn with hydrocephalus and no brain or of a child born with spina bifida "with a sack of brain fluid attached where all the nerves are floating around" - opens up terra incognita in a country at the forefront of the global debate on euthanasia.
Euthanasia has been practised for 10 years in the Netherlands, the first country in the world to legalise the practice, and now accounts for 4-5,000 deaths a year, 3.5% of the national death rate.
The practice is severely circumscribed and tightly regulated. It is estimated that doctors in the Netherlands, the only people allowed to perform euthanasia, turn down two-thirds of euthanasia requests.
Euthanasia is legal from the age of 12. It cannot apply to children because they cannot take a free decision. But several moves are afoot to extend euthanasia beyond the current limits.
For example, a national commission of experts concluded last week after three years of deliberation that euthanasia rights should be extended to those wanting to die because they are "tired of life". There is also a discussion about euthanasia for patients suffering from dementia, as well as about psychiatric and other cases involving patients unable to take a rational decision for themselves.
On top of these debates comes the discussion over newborns. The dilemma has triggered surprisingly little debate in the Netherlands, but has caused a storm of controversy outside, particularly among the religious right in the US and in the churches.
"From the point of view of the Netherlands, this debate about newborns is a logical development," says Professor Henk Jochemsen, a medical ethicist and Christian critic of euthanasia. "It's another step in the wrong direction."
Bishop Elio Sgreccia, of the Vatican's Pontifical Academy for Life, has written to the paediatricians to voice outrage at the proposals, likening them to the Nazis' mass murder of 70,000 physically and mentally disabled under the euphemism of euthanasia.
The Vatican accusations, in turn, caused great distress to the paediatricians who argue that they are only seeking to bring into the open what is already established practice, and not only in the Netherlands.
"It's not good that these very delicate and difficult decisions are done secretly," says Jost Wessel, a spokesman for the hospital in Groningen.
Dr Kollée says: "We want doctors who end the life of a baby to report the cases and that the cases are properly reviewed. The great majority of paediatricians have told us that these end-of-life decisions should be properly examined and not practised in the dark."
The paediatricians say that up to 15 children are killed at birth every year in the Netherlands and that worldwide the figure is around 600 a year.
Once a month on average somewhere in the Netherlands a doctor injects a newborn baby with a lethal cocktail of morphine and sedatives. Within a few hours, the baby is dead. The agonising decision is taken, invariably at the pleading of distraught parents, because the infant is born into excruciating pain with life-threatening illness or disability and with little or no prospect of recovery or successful treatment.
Routinely, the killings are carried out in secret. The reasons for the deaths are covered up. The death certificates the doctors are obliged to fill out are falsified in order to render the doctors immune to prosecution for murder.
"We know these cases are happening every year. There's a kind of consensus that it is justifiable," says Johan Legemaape, legal adviser to the Royal Dutch Medical Association. "But it's still a very sensitive subject and it raises a strong reaction."
The moral, psychological and emotional pressures raised by the topic of killing infants are daunting in the extreme, and in Holland, which has allowed strictly controlled euthanasia for 10 years, doctors are now demanding new rules governing the practice.
"It's time to be honest about the unbearable suffering endured by newborns with no hope of a future," said Dr Eduard Verhagen, head of paediatrics at Groningen hospital, in a statement last week. "All over the world doctors end lives discreetly out of compassion without any kind of regulation ... This is a subject that nobody likes to acknowledge, let alone discuss."
Professor Jochemsen worries about the implications of a favourable government response to the pressure from the paediatricians.
"These doctors say it is restricted to very clear diagnoses. But practice tells us it will be gradually extended to others. What is being considered now couldn't have been considered 10 years ago. It's the slippery slope."
Dr Kollée contends the very opposite: "If the practice is not controlled and regulated, then we will end up on the slippery slope. We don't want this type of decision to become easy. We don't want to increase the number of patients whose lives are terminated. It must be exceptional. It shouldn't be done. But sometimes a doctor can't do anything else."
Britain takes ethical stance
Luke Winston-Jones, 10 months old and terminally ill from heart defects and chronic respiratory problems, died last month. Charlotte Wyatt, 14 months old, has chronic lung disease. Doctors think she will pick up an infection this winter and slip away.
Their parents implored judges not to allow doctors to stop treating their babies. In both cases, the courts ruled that the babies be allowed to die in peace and comfort.
In most cases doctors and parents can reach agreement on what is best for the child. Usually, parents accept the medical verdict that the child will not survive for long. They may agree that the baby be given painkillers, but no treatment in order not to prolong the agony.
British doctors say they have no knowledge of cases where doctors have hastened a baby's death. It is against all the ethical guidelines, they say. Both the British Medical Association and the Royal College of Paediatrics and Child Health oppose euthanasia.
Harvey Marcovitch, of the Royal College, says he has never come across a case where a doctor has carried out a mercy killing on a baby. But he added: "If you talk to much older, retired paediatricians, they will tell you that years ago this was not uncommon practice." Newborn babies can these days be spared pain, he added.
Sarah Boseley, health editor
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