Special Section: International Voices Shifts in the Direction of Dutch Bioethics: Forward or Backward?

Important bioethcs changes are underway in the Netherlands that carry, for better or worse, far-reaching social consequences. The two major areas of change involve (1) economics and containing soaring health costs and (2) end-of-life care as reflected in several high-profile cases: in a decision handed down by the Dutch Supreme Court on reviewing the procedures for the termination of life, in the discussion surrounding The Groningen Protocol and the active ending of lives in neonatology, and in a report of a Royal Dutch Medical Society’s Committee on the role of physicians in ending life in cases of requests to die outside the area of terminal diseases. Each of these events and reports is described in broad outline below. Economics An appeal to Adam Smith’s “invisible hand” as a solution for rising health care costs? 1 For the past decades soaring healthcare costs have become a major source of worry for governments, institutions, and individuals in all Western countries. In response, Dutch politics has moved away from state-controlled socialized welfare by distancing state involvement, by delegating the management and control of social tasks to the direct stakeholders, and by converting former state institutions into private enterprises, thus creating a “government at a distance” policy. Successive governments, formed by Liberals, Social Democrats, and Christian Democrats, have made a significant departure from the traditional two-tiered system of healthcare insurance introduced during the Second World War that was modeled after the German system. Until now there has been mandatory insurance for lower income groups and voluntary insurance for the higher income classes. Several changes with moral significance for the system have already been decided or are intended for future implementation. The concept of “solidarity” as the basis for payment (i.e., the plan in which people pay a fee commensurate with their risk and the funds collected are sufficient to cover expenditures but produce no profit) is being replaced. Instead, the new plan is for a system of obligated insurance that provides a basket of basic primary healthcare provisions, with options for individuals to get supplemental coverage for risks not otherwise covered. Thus, there is a shift away from state-centered responsibility in which the state controls the price of healthcare premiums in contrast to the market setting the price without government interference. Not-for-profit institutions have become for profit, more or less like making the foxes responsible