Martin Davies

Previous Ethics briefings reported on research developments involving mitochondrial transfer to allow women to avoid passing on a serious mitochondrial disease to their daughters.1 This update reports on the beginning of the legal process that could see the procedure used in clinical practice. The Human Fertilisation and Embryology Act 1990 (as amended) allows for regulations to be passed that permit techniques that alter the mitochondrial DNA of an egg or embryo to be used in assisted conception to prevent the transmission of serious mitochondrial disease. This involves the pronuclei (containing the genetic material from the egg and sperm) being removed from a fertilised oocyte and transferred into a fertilised donor egg that has had its own pronuclei removed—this is called pronuclear transfer (PNT). Another option is maternal spindle transfer (MST) whereby the spindle containing the woman's nuclear genetic material is transferred into an enucleated donor egg, which is then fertilised with the man's sperm. In both cases the resultant fertilised egg contains nuclear DNA from the father and mother and mitochondrial DNA from the donor. If successful, these techniques would avoid mitochondrial disease in the resulting child and also in future generations. In February 2011 the Secretary of State for Health asked the Human Fertilisation and Embryology Authority to carry out a scientific review into the effectiveness and safety of these forms of mitochondrial transfer. Having carried out a detailed analysis of the existing research base, the Human Fertilisation and Embryology Authority concluded that there was no evidence that these techniques were unsafe but that some further safety experiments needed to be carried out before either technique could be introduced into clinical practice.2 It recommended the following minimum set of basic experiments that needed to be undertaken before the techniques could be assessed as safe for use in …

Article 5 of the European Convention on Human Rights (ECHR) guarantees individual liberty. It prohibits arbitrary deprivations of liberty: any deprivation of liberty must be subject to certain safeguards, including the ability to refer any such deprivation for appropriate legal review. In October 2004 the European Court of Human Rights (ECtHR) handed down a judgement in what has come to be known as the Bournewood case.1 In brief, the Court ruled that the individual in question, known as HL, had been unlawfully deprived of liberty while being informally admitted in a British psychiatric hospital. HL lacked the capacity to consent to the arrangements for his care and, as he was compliant with those arrangements, he was not formally detained under the Mental Health Act. Although the British House of Lords held, by a majority, that HL had not been unlawfully detained under the common law, the ECtHR held that his detention was in breach Article 5 ECHR.2 In response to the European Court ruling, the UK Government introduced, via an amendment to the Mental Capacity Act 2005 (MCA), the Deprivation of Liberty Safeguards (DoLS). (The MCA only applies to England and Wales. Governments in Scotland and Northern Ireland have made their own arrangements in response to the ECtHR ruling.) These safeguards were designed to ensure that whenever an individual was identified as being provided with care or treatment in circumstances that amount, or might amount, to a deprivation of liberty, certain safeguards were in place. These were designed to ensure that any such deprivation was necessary, proportionate and in the individual's best interest. DoLS are a procedural arrangement to ensure ECHR compliance. From the outset concerns were expressed about their complexity, their administrative burden, and, critically, their ability to provide the kinds of protection that vulnerable adults required. …

Although the optimism of those times seems to have passed out of memory, the origins of the Syrian civil war reach back to the ‘Arab Spring’ and a burst of political hope throughout the Middle East. Although some countries saw regime change, since 2011, Syria has been engulfed in an increasingly brutal civil war. The war has seen sustained violations of International Humanitarian Law, including the use of the nerve agent sarin—its use being described by President Obama in June 2013 as ‘crossing a red line’.1 As the war has intensified, so the breaches of International Humanitarian Law, including the Geneva Conventions, have increased. The Geneva Conventions seek to bring specified forms of restraint in the waging of war. Article 24 of the 1949 Geneva Convention I states that:Medical personnel exclusively engaged in the search for, or the collection, transport or treatment of, the wounded or sick, or in the prevention of disease, staff exclusively engaged in the administration of medical units and establishments … shall be respected and protected in all circumstances2 At the beginning of 2016, Amnesty International issued a press release stating that Russia and Syria were targeting hospitals ‘as a strategy of war’. According to Amnesty, during the first 3 months of 2016 they gathered ‘compelling evidence of at least six deliberate attacks on hospitals, medical centres and clinics in the northern part of the Aleppo Countryside governorate’.3 Breaches of medical neutrality have not been confined to Syria. The civil war in Yemen, where a Saudi-led coalition is supporting the government against a Houthi militia, has also seen systematic attacks on health facilities.4 The sustained and deliberate nature of these attacks in Syria, Yemen and beyond have led senior humanitarian commentators to talk of normalisation, an emerging acceptance that hospitals and medical …

The Supreme Court has ruled in the case of Y that there is no requirement to seek the approval of the Court of Protection in decisions to withdraw clinically assisted nutrition and hydration from patients in a prolonged disorder of consciousness.1 Mr Y was 52-year-old man who suffered a cardiac arrest after a myocardial infarction as a result of coronary artery disease. It was not possible to resuscitate him for well over 10 min, resulting in severe cerebral hypoxia which caused extensive brain damage. Mr Y’s family and the NHS Trust treating him agreed that Mr Y would not want to be kept alive through the provision of CANH given his poor prognosis. They sought a declaration that it was not mandatory for applications of withdrawal of CANH to come before the court, which was granted by Mrs Justice O’Farrell in the first instance.2 Permission was granted for the appeal to ‘leapfrog’ the Court of Appeal and to proceed to the Supreme Court for consideration. In the interim, Mr Y died after contracting acute respiratory sepsis, but the Supreme Court determined that the appeal should go ahead in light of the general importance of the issues raised. In delivering the opinion of the Supreme Court on 30 July 2018, Lady Justice Black rejected the historical distinction that had been drawn between patients in PDOC and non-PDOC patients, in a way that had justified judicial involvement for patients in PDOC but not for others.3 She was clear that the correct approach to all cases involving CANH was to make a decision based on what was in the best interests of the patient. She further outlined that: > The documentation supplied to us shows that the difficulty that there is in assessing the patient and in …

In April, the UK House of Commons Science and Technology committee published a report evaluating the readiness of the National Health Service to incorporate genomic testing into mainstream service provision.1 The committee also examined some of the research and regulatory considerations in relation to the ongoing development of genome editing. ### Genomics in the NHS The main focus of the report is the 100,000 Genomes Project and the various practical and ethical challenges associated with the planned roll-out of the Genomics Medicine Service in the NHS. The 1 00 000 Genomes Project was launched in 2012 and is the first large-scale whole genome sequencing research study of its kind in the world. The overall objective is to sequence genomes from NHS patients with a rare disease and their families, and from patients with specific cancers. The study seeks to benefit patients by potentially providing a diagnosis, gain new scientific insights, increase public knowledge of genomic medicine, encourage investment, and accelerate the uptake of genomic medicine in the NHS. At the time of writing the project had sequenced over 55 000 genomes and it is expected that the full 1 00 000 will be completed by the end of 2018. Building on the success of the project NHS England announced the establishment of a national NHS Genomic Medicine Service to provide ‘comprehensive and equitable access to the latest in genomic testing and management for the whole country, regardless of condition and where people live.’2 The service is set to be operational this year. The committee acknowledged the range of potential benefits that whole genome sequencing could have for patient care, however it also highlighted that there was a currently a lack of ‘sufficiently unambiguous evidence’ for its …

### High Court rejects assisted dying challenge The High Court has rejected the latest challenge to the law on assisted dying in the UK, brought by Noel Conway. Mr Conway, a retired college lecturer, was diagnosed with motor neuron disease in 2012. Since his diagnosis, his health has deteriorated and he is dependent on ever-increasing levels of assistance with daily life, including the use of non-invasive ventilation to help him breathe. He sought a declaration from the court that section 2 of the Suicide Act 1961 was incompatible with his right to a private and family life under Article 8 of the European Convention on Human Rights. As part of his case, Mr Conway submitted the outline of an alternative statutory scheme, which he argued, if implemented, would provide sufficient safeguards. He submitted that the prohibition on assisted suicide should not apply where an individual is aged 18 and over; has been diagnosed with a terminal illness and has a clinically assessed prognosis of 6 months or less to live; has the mental capacity to make the decision; makes that decision in a voluntary, clear and settled manner; and retains the ability to undertake the final act. Additionally, two doctors must confirm that the individual meets the criteria, and permission for the provision of assistance must be authorised by a High Court judge. Previous challenges to the UK law on assisted dying, including Pretty and Nicklinson, had established that section 2 of the Suicide Act does engage individual’s Article 18 rights, but that such an interference could be justified under Article 8 of the ECHR, which permits interference ‘such as is in accordance with the law and necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country’. The question …

At the end of 2015, Northern Ireland's (NI) High Court of Justice ruled that NI abortion legislation breaches Article 8 of the European Convention on Human Rights—the right to respect for private and family life. The law breaches the Convention as it does not enable women to seek abortion for: At the time of writing, it was not known if NI's Department of Justice and Executive would appeal the decision or bring forward legislation to reflect the judgment. In November 2015, the High Court handed down a judgment in a case involving the recording of a do not attempt cardiopulmonary resuscitation (DNACPR) decision for a 28-year-old man who lacked capacity.2 The judgment has raised a number of interesting questions about when it would not be ‘practical and appropriate’ to ‘consult’ those close to the patient of a DNACPR decision, and what might be a ‘compelling obstacle’ to consultation. In the case, a DNACPR decision was made at 3:00 in the morning as the doctor believed that cardiopulmonary resuscitation (CPR) would have no chance of success. The doctor did not think there was imminent risk of a cardiopulmonary arrest but wished to avoid the possibility of nursing staff being obliged to attempt CPR. At the time the decision was made and documented, no one close to the patient was consulted or informed, instead “DNAR. Speak to family in the morning” was recorded. In the judgment, The Honourable Mr Justice Blake concluded that there had been a breach of section 4(7) duty to consult under the Mental Capacity Act 2005 (MCA) and there had been a violation of the procedural duty under …

Previous Ethics briefings have charted the unprecedented developments in relation to the law on abortion in Northern Ireland this year,1 resulting in legislation being passed by the UK government that ‘decriminalised’ abortion in Northern Ireland, up to the point at which a fetus ‘is capable of being born alive’, from 22 October 2019. A new legal framework and supporting guidelines on abortion are now set to be introduced by 31 March 2020—which should reflect the recommendations in the 2018 United Nations’ Committee on the Elimination of Discrimination against Women report on abortion in Northern Ireland.2 ### Interim guidance In anticipation of this period between decriminalisation and the introduction of a new legal framework, on 7 October 2019 the UK government’s Northern Ireland Office published interim factual guidance for healthcare professionals on their responsibilities to patients in light of these changes.3 Among other things, the guidance notes that there are no plans for additional services to be routinely available in Northern Ireland before 31 March 2020. There will, however, be fewer restrictions on which women in Northern Ireland can access funded abortion services in England via the Central Booking Service—doctors should direct women to this service.4 If healthcare professionals do offer additional abortion services in Northern Ireland itself ‘they should do so in line with their professional competence and guidance from their professional body’. The guidance recognises that some women may still purchase drugs that cause abortions online during this interim period. The difference now is that should a woman require medical assistance as a result, there is no obligation on healthcare professionals to report the woman to the police as abortion, in these circumstances, is not a crime. Previously, under section 5 of the Criminal Law Act (Northern Ireland) 1967 a legal duty, unique to Northern Ireland, was placed …

In July, the National Data Guardian (NDG) for health and care in England, Dame Fiona Caldicott, published her Review of Data Security, Consent and Opt-Outs.1 The role of NDG was created in 2014 to advise and challenge the health and care system to help ensure that citizens' personal confidential information is safeguarded securely and used properly. The review makes 20 recommendations to the Department of Health, including proposals for 10 new data security standards for the National Health Service (NHS) and social care, a method for testing compliance against the standards and a new ‘eight-point’ model for consent and opt-out for sharing personal confidential information for purposes beyond an individual's direct care. ### Data security The review heard that 41% of all breaches reported to the UK Information Commissioner's Office (ICO) were from the health sector.2 The review concluded that the breaches were caused by people, process and technology and have based the recommendations and standards around these three themes. Dame Fiona proposes 10 data security standards that would apply in every health and care organisation which handles personal confidential information. These include measures which will protect systems against data breaches and ensure that organisations are as prepared as they can be to meet the challenges of the digital age and the growing threat from cyber-attacks. Strong leadership was considered to be crucial to data security. The 10 data security standards are therefore clustered under three leadership obligations: ### Consent/opt-out of information sharing in health and social care The review makes nine recommendations in relation to consent and opt-out. One of the recommendations puts forward a new ‘eight-point’ …

In Montgomery v Lanarkshire Health Board, the Supreme Court has clarified the law in relation to informed consent.1 When seeking consent, doctors must take reasonable steps to ensure that the patient is aware of the material risks of any treatments they offer and of the availability of any reasonable alternatives. Doctors can no longer rely on a responsible body of medical opinion—the Bolam test—when assessing what information they should provide to patients. The patient in the case was an insulin dependent diabetic pregnant woman. Diabetic women frequently have larger than normal babies, which leads to a heightened risk of shoulder dystocia where the baby's shoulders cannot pass through the pelvis. Her consultant did not inform her either of the 9%–10% risk of shoulder dystocia or of the possibility of delivery by caesarean section. During delivery the umbilical cord was occluded and her son was born with cerebral palsy and with a paralysis of the arm resulting from the vigorous manipulation required to deliver him. The court held that the consultant should have informed the patient of the risks of shoulder dystocia and discussed the possibility of a caesarean section. The court also set out doctors’ legal obligations in relation to information provision when seeking consent. Doctors must ‘take reasonable care to ensure that the patient is aware of any material risks involved in any treatment and of any reasonable alternative or variant treatments’.2 A ‘material risk’ is one in which ‘a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it’.3 When discussing risk with patients, percentages alone are insufficient. Important factors will include ‘the nature of the risk, …

The Mental Capacity Act (2005) for England and Wales came into force in 2007. It was designed to codify the law in relation to decision making on behalf of adults lacking the capacity to make specified decisions on their own behalf. In 2013, the House of Lords established a Select Committee on the Act in order to explore how well it was achieving its aims and whether any substantive amendments were required.1 In particular the Committee wanted to identify whether the Act was achieving an appropriate balance between enabling adults who may have impaired capacity to make as many decisions as possible and providing protection to those adults who needed it. The British Medical Association (BMA) submitted a written response to the Committee's call for evidence. Although in general strongly supportive of the Act, the BMA raised some concerns about the lack of awareness among front-line health professionals. In addition, the BMA expressed concerns that in some instances, in the absence of a binding advance decision, insufficient weight was given to the prior competent wishes of adults now lacking capacity. The scrutiny committee also invited views on whether the Act was compliant with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). The Convention requires equal treatment for all disabled people, irrespective of whether their disabilities are physical or mental. Article 12 of the Convention requires that “persons with disabilities have the right to recognition everywhere as persons before the law”.2 It is possible that a right to equal recognition before the law could render the Mental Capacity Act's surrogate decision-making regime unlawful. Along with several other medical bodies, the BMA was invited to give oral evidence to the scrutiny committee. The Committee was particularly interested in identifying what medical bodies could do both to …

### Marris Bill In June 2015, Labour Member of Parliament (MP) Rob Marris, who topped the ballot for private members’ bills, introduced the Assisted Dying (No. 2) Bill (‘the Marris Bill’) into the House of Commons. The Marris Bill was nearly identical to the Falconer Bill debated in the House of Lords early in the year (Eth 20, 2014–2015), and would permit competent, terminally ill adults with a clear and settled intention to end their life to receive physician assistance to do so. Two doctors must be satisfied that the persons are terminally ill and are reasonably expected to die within 6 months, have the capacity (construed in accordance with the Mental Capacity Act 2005) and have a clear and settled intention to end their lives, which have been reached voluntarily, on an informed basis. The Marris Bill also included one of the amendments approved at Committee Stage of the Falconer Bill, which, in addition to the need for two doctors to be satisfied as to the eligibility criteria, would require all requests to be approved by a judge of the High Court (Family Division). Further to this, the Marris Bill included two new clauses: first, a requirement for High Court Judges to rule on requests within 14 days1 and, second, a requirement for any doctor with doubts about the capacity of a person requesting assistance to refer that person for assessment to ‘an appropriate specialist’.2 The Marris Bill received its second reading in the House of Commons on 11 September 2015, where it was overwhelmingly rejected by 330 votes to 118.3 A large number of those who opposed the Bill did so on the grounds that it had the potential to go beyond its limits and to pressurise the elderly and other vulnerable people, particularly those without family support, to consider …

Essex University, in association with Johns Hopkins Center for Public Health and Human Rights, has brought out a timely report highlighting the increasing global criminalisation of the provision of healthcare.1 The report, with a foreword by Professor Dainius Puras, United Nations Special Rapporteur on the right to health, explores the pressures on medical impartiality arising in large part from both global and national responses to the threat of terrorism. Both international humanitarian law, human rights law and long-established principles of medical ethics—as set out in various declarations of the World Medical Association—establish an absolute principle that all people, regardless of their beliefs, affiliation or status, have rights of access to appropriate healthcare. And this right extends to wounded and sick combatants, as well as civilians, during times of armed conflict. One of the challenges in this area is that in recent years, many conflicts have become ‘asymmetric’. Contemporary conflicts seldom involve opposing state armies. Instead, they increasingly involve irregular combatants, often labelled ‘terrorists’ or ‘insurgents’ by the states they are opposing. In response to these threats, many states have developed sometimes draconian legislation outlawing terrorist groups and those offering support. The danger, outlined in some detail in the report, is that the vital distinction between the impartial provision of medical care and the criminal offence of materially aiding terrorism is lost. In 2016, largely in response to the deliberate targeting of healthcare personnel and facilities in the conflicts disfiguring the greater Middle …

Erdoğan intensifies assault on Turkish civil society Deeply worrying reports from the Turkish Medical Association suggest that the Turkish President Recep Erdoğan is hardening his attack on civil society in Turkey, using the legitimate activities of the TTB as the flimsiest of pretexts. In January 2018, the TTB issued a short statement raising concerns about the impact on public health of Turkey’s military operation in the Kurdish-controlled region of northern Syria. It denounced the operation saying ‘No to war, peace immediately’. In response to the Association’s press release, the Turkish president publicly accused the 83 000 strong TTB of being terrorist sympathisers. ‘This institution has nothing to do with Turkishness and nothing about them is worthy of the notion of Turkishness’, he said. 1 Eleven of its senior doctors, including the Association’s chairman, were later detained following an order from a Turkish prosecutor. President Erdoğan made it...

Re AA and Re P : the ‘forced caesarean’ caseOn 30 November 2013 The Telegraph reported that Essex County Council Social Services had obtained a High Court Order against a woman that allowed her to be forcibly sedated and her child removed by caesarean section and taken into care.1 The original story reported that the woman, an Italian national who had been in the UK on a short-term basis for work, had experienced ‘something of a panic attack’ and, after calling the police, was compulsorily detained under the Mental Health Act 1983. Five weeks later, the report said, she was restrained, forcibly sedated and awoke hours later to find that, pursuant to a court order obtained by Essex County Council Social Services, her baby had been removed by caesarean section and taken into care by social workers.The story was subsequently reported in a number of other media outlets and prompted such widespread outrage that the presiding judge, Mr Justice Mostyn, took the unprecedented step of releasing both the judgement of the initial application to the Court of Protection and the verbatim transcript of proceedings. It became apparent that the facts of the case had been drastically misreported by the media and that coverage had conflated two very separate issues: the medical procedure of the caesarean section and the taking of the child into local authority care.The initial case heard in the Court of Protection on 23 August 2012, Re AA,2 was the result of an application made not by the local authority or social workers seeking to remove the child but by Mid-Essex National Health Service Trust seeking a declaration and an order, on the basis of medical evidence, that the patient lacked capacity and that it would be in her best interests to undergo a caesarean section. Mr Justice Mostyn found in …

In April 2014, the European Parliament agreed the final text on a new EU Clinical Trials Regulation.1 The Regulation replaces the EU Clinical Trials Directive, which has long been criticised by various stakeholders for creating unnecessary bureaucracy and blamed, at least in part, for increased costs, time delays and a drop in clinical trial applications. The new Regulation seeks to remedy the faults of the previous legislation and make the EU an attractive place to conduct clinical trials.The Regulation aims to streamline and harmonise the administrative procedures for clinical trial approvals but without compromising the safety of participants. A particular focus is placed on the importance of enabling trials in multiple or all member states, recognising that there is an increasing need to target ever more specific patient populations and the challenge this represents in recruiting sufficient numbers of participants to research studies. A new, two-part application process, designed to avoid the multiple submission of identical data is therefore to be introduced. Member states cooperate on certain aspects of trial approval but issues which are subject to specific national regulations will continue to be approved by individual countries. All applications will be submitted through a new EU portal, which will be set up and managed by the European Medicines Agency. The new process also takes a risk-based approach to some types of research study. Trials to test medicinal products that already have a marketing authorisation are classed as ‘low intervention trials’ and are subject to less stringent requirements.The ethical safeguards in the new Regulation remain similar to those in the 2001 Directive. A positive appraisal from a research ethics committee remains a prerequisite for a trial to be approved. Member …

Doctors and medical students in the UK have voted in support of the decriminalisation of abortion for women who self-administer abortions and healthcare professionals who provide abortions within the context of their clinical practice. Abortion should be treated as a medical issue rather than a criminal one. ### Background to the vote The vote took place at the end of June during the British Medical Association’s Annual Representative Meeting, where representatives of doctors and medical students from across the British Isles gathered to set BMA policy through democratic procedures. Representatives considered the issue of decriminalisation during a 2-hour debate, where diverse and opposing viewpoints were heard. The debate was informed by a neutral discussion paper that was published by the BMA in February, which provided a guide to some of the key legal and ethical issues raised by the debate around decriminalisation.1 The BMA’s new policy only relates to whether abortion should or should not be a criminal offence; the policy does not address the broader issue of when and how abortion should be available. The BMA has established policy on these issues which remains unchanged.2 ### The law on abortion Induced abortion is currently a crime throughout the British Isles. There are, however, a range of exceptions to the crime laid out in statute and/or common law, for example, in England, Scotland and Wales, under the Abortion Act 1967. Any healthcare professionals operating within those defined exceptions, which include grounds for authorising an abortion and procedural requirements, can lawfully carry out an abortion as a clinical procedure. Outside these defined exceptions, the criminal offences potentially apply both to those who participate in carrying out abortions for others, including doctors, nurses and midwives, and to women who carry out abortions on themselves. For example, healthcare professionals who do not follow procedural requirements can attract criminal sanctions …

The British Medical Association has published a new report on health and human rights in immigration detention in the UK. Locked up, locked out outlines how aspects of current detention policies and practices are detrimental to the health of those detained and the challenges doctors face in providing healthcare in the immigration detention setting. It makes a number of recommendations aimed at addressing policy and practice which impact on health and well-being, including calling for an end to the routine use of detention as a means of monitoring those facing removal from the UK and for the introduction of a time limit on the length of time individuals can be detained. It also provides guidance for doctors working in these settings on some of the common ethical and professional dilemmas they may face. The report can be accessed and downloaded at www.bma.org.uk/immigrationdetention. The Government has announced its intention to review mental health legislation for England and, in relation to non-devolved issues, for Wales.1 The Government states that it is ‘committed to delivering parity of esteem between mental and physical health’, although it does not clarify the meaning of ‘parity of esteem’. Similarly, the Government states that it wants to ensure that people with mental health problems ‘are treated with dignity, and that their liberty and autonomy is respected as far as possible’. Again, the Government has not indicated the meaning of ‘as far as possible’. Although not directly mentioned in the review’s terms of reference, it must be set against the background of changing legal and ethical expectations in relation to the rights of those with mental or cognitive disorders and disabilities. The UK is a signatory to the United Nations Convention on the Rights of People with …

In February 2014, the Belgian Parliament passed legislation allowing euthanasia for terminally ill children of all ages by 86 votes to 44, with 12 abstentions. The Bill became law in early March after being signed by the King, making Belgium the first country in the world to abolish age restrictions for euthanasia. Previously, the youngest age at which euthanasia was permitted was 12 years old in The Netherlands.1 Euthanasia was legalised in Belgium in 2002, and the new legislation introduces amendments to the law extending euthanasia to minors in certain circumstances. Euthanasia is now permissible for children of all ages where the child has a “terminal and incurable illness”, experiences “constant and unbearable physical suffering”, and death is expected to occur within a “brief period”. The child must be deemed capable of making the decision, and have the agreement of their parents. Belgian law sets no timetable for euthanasia from the point at which the patient first expresses a wish to die. As with adults seeking euthanasia, any request must be made in writing. A physician and “outsider” brought in to give a second opinion must agree upon the diagnosis and prognosis, and a paediatric psychiatrist or psychologist must certify in writing that the child possesses “the capacity of discernment”. Following this, the child's physician must meet with the parents to inform them of the outcome of the consultation and ensure they are in agreement with the child's request. The child and the family must receive psychological care and support if so desired. The move provoked heated debate and divided the medical, legal and political professions in Belgium. A group of 160 of the country's paediatricians opposed a change in the law, citing concerns about the largely subjective assessment of the “capacity of discernment”, and drawing attention to advances in …