FROM THE EDITOR
A team of a team of undercover freelance investigative journalists called the Center for Medical Progress has been making life miserable for abortion provider Planned Parenthood over the past few weeks (while we were on holiday, sorry about the gap in coverage).
In a recent editorial the New York Times accused this unknown group of being, um, journalists. “The Center for Medical Progress video campaign is a dishonest attempt to make legal, voluntary and potentially lifesaving tissue donations appear nefarious and illegal.”
Well, actually, that’s not quite the case. It’s an attempt to see whether the donations are in fact legal and voluntary. Journalists tend to do that sort of thing. Being sceptical about bland reassurances from organisations with budgets of over $1 billion is kind of part of their job description.
This clothespeg-on-the-nose attitude is odd for a newspaper whose motto is “All the News That’s Fit to Print”. And even odder for a newspaper which defied the President of the United States by publishing revelations obtained illegally by whistleblower Edward Snowden. It editorialised at the time:
“Mr. Snowden was clearly justified in believing that the only way to blow the whistle on this kind of intelligence-gathering was to expose it to the public and let the resulting furor do the work his superiors would not.”
Large organisations like the National Security Agency, Phillip Morris or the Galleon Hedge Fund tend to deny that they ever have done, are doing or ever will do anything which is nefarious and illegal. That’s what their public relations staff are paid to say. What is extraordinary is that America’s paper of record has become an unpaid extension of Planned Parenthood’s PR office.Click Here to Comment on this letter
|This week in BioEdge|
The use of foetal tissue in biomedical research has become an incendiary political issue in the United States. Four videos have been released by freelance investigative journalists working undercover which purport to show that abortion provider Planned Parenthood (PP) is illegally selling foetal body parts.
Planned Parenthood has vehemently denied that it is breaking any laws by supplying tissue from abortions to tissue companies. It also points out that scientists have used foetal tissue to develop life-saving vaccines for polio, rubella, and chicken pox.
At stake are hundreds of millions of dollars in government funding. According to the news site Politico, the annual total is US$528 million. Some Senators and Congressmen are vowing to do everything they can to defund Planned Parenthood. “This is one of those line-in-the-sand type of issues,” Rep Rick Mulvaney, a South Carolina Republican told Politico.
Funding for PP has always been a divisive issue, but the videos made by a group called the Center for Medical Progress (CMP) are explosive. Four have been released so far and the spokesman for CMP, David Daleiden, says that he hope to release another 8 or 10.
A California court has issued an injunction banning the release of a fifth video.
Several ethical issues crop up in media coverage of the controversy. First, CMP maintains that by charging tissue companies for body parts from aborted foetuses, PP is breaching Federal laws which ban the sale of human organs. PP responds that it is just charging small amounts to cover handling costs.
Second, the sting videos are a reminder of on-going debate over the use of aborted tissue in medical research. Even bioethicist Art Caplan, who does not oppose abortion, has some reservations. "It shifts the focus away from the women and their needs," he told the website Vox. "It makes Planned Parenthood or any abortion clinic look like it's trying to generate some other source of income, and it puts the clinic in a position that generates a lot of unease."
Third, the victims of the sting complain that this is unethical journalism and that privacy laws have been violated. After similar incidents in the past, even some abortion foes had misgivings about gaining information under false pretenses.
Some scenes in the videos are disturbing, even stomach-turning. The first features a lunchtime conversation with Deborah Nucatola, PP’s senior director of medical services. In it she discusses prices for specimens and how an abortion technique can be varied to extract more intact body parts. The second features Mary Gatter, president of PP’s Medical Directors Council who discusses similar issues. In the third, a former PP employee alleges that it profits from the transactions. In the fourth, employees sort through body parts in a dish.
The release of the videos was well-timed. July is a slow news month and politicians are in the middle of preparations for next year’s election. The controversy offers Republicans a splendid opportunity to embarrass President Obama, a firm friend of PP. Each video ratchets up seriousness of the allegations and the yuk factor, so some very gruesome viewing could lie ahead.
Predictably, the allies of PP are digging furiously for dirt on Daleiden and the CMP. Pro-life supporters, on the other hand, are focusing on the images of baby body parts being sorted in a pie plate and offensive language by PP representatives (“… we’ve been very good at getting heart, lung, liver, because we know that, so I’m not gonna crush that part, I’m gonna basically crush below, I’m gonna crush above, and I’m gonna see if I can get it all intact.”).
Where is the debate going? It depends to some extent on whether sorting through body parts outrages the public as much as it outrages politicians. If Google is any guide, the public may not be all that interested. A search for “Planned Parenthood videos” brought up 12 million results. A search for “Cecil the lion”, who was killed in Zimbabwe by a dentist from Minnesota, brought up 51 million.
The use of torture to extract information from terrorist detainees under the Bush Administration continues to reverberate. A searing report on collusion of officials in the American Psychological Association with the government has led to a crisis in the organization. Next weekend’s annual conference in Toronto will be a fiery one.
The independent report commissioned by the APA documents how APA and government officials created a legal and ethical justification for the torture program, which relied on health professional monitoring of abusive interrogations to claim that they were “safe, effective, and legal.”
What concerns the APA rank and file is that the people responsible for working hand in glove with the government were not “rogue officials”, but psychologists working at the top of the APA. The leading figure was the APA’s ethics director, Stephen Behnke. Others involved included the president, the president-elect, the CEO, deputy CEO, general counsel and the communications director.
“Rather than uphold the principle of ‘do no harm,’ APA leadership subverted its own ethics policies and sabotaged all efforts at enforcement,” said Donna McKay, executive director of Physicians for Human Rights, a persistent critic of the APA’s policy.
The report, written by David Hoffman, a former federal prosecutor, concluded that “APA’s principal motive in doing so was to align APA and curry favor with DoD. There were two other important motives: to create a good public-relations response, and to keep the growth of psychology unrestrained in this area.”
It also appears that APA officials may have engaged in criminal behaviour by:
“As mental health professionals, our first obligation must be to our patients,” said Dr. Kerry Sulkowicz, a psychiatrist with the Physicans for Human Right. “The APA’s collusion with the government’s national security apparatus is one of the greatest scandals in US medical history. Immediate action must be taken to restore health professional ethics and to ensure this never happens again.”
The comfortable certainty of having at least half a brain is unshakable. It is so beyond dispute that the philosopher Ludwig Wittgenstein used it as an example of knowledge that is certain even though we have no sensory experience to confirm it. However, biologist Donald R. Forsdyke, of Queen’s University, in Canada, points out in the journal Biological Theory that we need to account for cases of people who have led normal lives without a brain. Or, to be more precise, about 5% of a normal brain.
Brain scans of some recovered hydrocephalics show a vast area filled with fluid where other people had brain tissue. Their brain, what is left of it, has been compressed around the skull. Yet one of them went on to get a first class honours degree in mathematics. Clearly information-related content does not scale with brain size.
The conventional explanation for this is that brains have enormous redundancy and plasticity. But Forsdyke is sceptical: “The drastic reduction in brain mass in the hydrocephalic cases seems to demand unimaginable levels of redundancy and/or plasticity—superplasticity. How much brain must be absent before we abandon these explanations and admit that the standard model, however incarnated, will not work?”
So what other explanations could there be?
Forsdyke lists three. First, “Information relating to long-term memory is held within the brain in some chemical or physical form consistent with current knowledge of brain chemistry and physiology”. Second, “Information relating to long-term memory is held within the brain in some extremely minute, subatomic, form, as yet unknown to biochemists and physiologists.” And even more controversially, “Information relating to long-term memory is held outside the brain.”
The last of these, extracorporeal information storage, appeals to Forsdyke. Invoking Sherlock Holmes, he says, “How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth?”
At the Neuroskeptic blog, however, it is argued that there is still no need to discard medical textbooks. The author says that the brain’s grey matter seems to be intact. The missing white matter, which normally provides connectivity, may be present but greatly compressed. More investigation is needed.
A TV show called “If Katie Hopkins Ruled the World” debuts next week in Britain. Ms Hopkins, a 40-year-old reality TV celebrity and a columnist for The Sun newspaper is what envious journalists call a “professional troll”. Whenever she opens her mouth, she hogs the headlines. The "queen of quotes" recently called for gunships to deter illegal migrants into Europe, calling them “feral humans” and “cockroaches” who are “spreading like norovirus”.
Now she has swiveled her guns to take aim at the elderly. In a radio interview promoting her new show, she declared “We just have far too many old people”. If she were in charge, she knows what to do: “It's ridiculous to be living in a country where we can put dogs to sleep but not people,” she told her 69-year-old interviewer. She believes that the problem is readily solved.
“Easy. Euthanasia vans – just like ice-cream vans – that would come to your home. It would all be perfectly charming. They might even have a nice little tune they'd play.
“I mean this genuinely. I'm super-keen on euthanasia vans. We need to accept that just because medical advances mean we can live longer, it's not necessarily the right thing to do.”
Ms Hopkins is a lean mean vilification machine but her views resonate with many people. Some 300,000 people signed a petition demanding that The Sun sack her and The Sun did not sack her. Instead she now has her own television show. And if she wants to follow up her idea of euthanasia vans playing Greensleeves, she can always ring up the Dutch right-to-die group NVVE. It is already offering the service.
A luminary at Harvard who is one of America’s leading intellectuals has aimed a haymaker at the whole field of bioethics. Writing in the Boston Globe today, celebrity psychologist Steven Pinker says: “the primary moral goal for today’s bioethics can be summarized in a single sentence. Get out of the way.”
Pinker, the author of best-sellers like The Better Angels of Our Nature and How the Mind Works, feels that the job description of contemporary bioethicists is to slow down biomedical progress or to stop it altogether. His target is not merely conservative ethicists like Leon Kass, with whom he had a famous dust-up in the National Review in 2008 over “the stupidity of dignity”, but all bioethical discourse.
“A truly ethical bioethics should not bog down research in red tape, moratoria, or threats of prosecution based on nebulous but sweeping principles such as ‘dignity,’ ‘sacredness,’ or ‘social justice.’ Nor should it thwart research that has likely benefits now or in the near future by sowing panic about speculative harms in the distant future. These include perverse analogies with nuclear weapons and Nazi atrocities, science-fiction dystopias like ‘Brave New World’’ and ‘Gattaca,’’ and freak-show scenarios like armies of cloned Hitlers, people selling their eyeballs on eBay, or warehouses of zombies to supply people with spare organs. Of course, individuals must be protected from identifiable harm, but we already have ample safeguards for the safety and informed consent of patients and research subjects.”
Should we be cautious? Not if it means slowing down the inevitable spread of progress.
“Some say that it’s simple prudence to pause and consider the long-term implications of research before it rushes headlong into changing the human condition. But this is an illusion. First, slowing down research has a massive human cost. Even a one-year delay in implementing an effective treatment could spell death, suffering, or disability for millions of people. Second, technological prediction beyond a horizon of a few years is so futile that any policy based on it is almost certain to do more harm than good.”
The availability of both IVF and abortion creates some counterintuitive situations. The latest issue of Cosmopolitan – not the world’s leading bioethics journal, but a good source of first-person narratives – features a Minnesota woman who aborted her first child, had one naturally, three through IVF, and then aborted an unexpected natural pregnancy.
Hannah Stein first fell pregnant at 22 before she married her partner Patrick. She says, “I felt too young, and there were too many other things I wanted to do first. I did not feel settled enough in my life to start having children.” So she had an abortion and shortly afterwards married Patrick.
Their first child came soon afterwards. But having a second was harder. So they resorted to IVF. She became pregnant twice, the second time with twins. At one stage, she miscarried, which distressed her immensely, even though the abortion did not.
“… regarding the miscarriage, I mourned, not because I thought it was a death of a child, exactly, but because I really wanted to have a child and I thought I was having one and then that opportunity was gone.”
Then, unexpectedly, she fell pregnant again. She opted for an abortion, convinced, as Cosmopolitan notes, “that a person should be able to choose if she wants to end a pregnancy.”
“The very idea of having another child at that point was terrifying to both of us. We had two 1-year-old babies and we had two older children. We were both working. There was no way. There was no energy, period, at that time. We were holding on by our fingernails.”
How could she justify the abortion of a naturally-conceived child when she had endured the agony of IVF? It’s a good question, she says:
“It's like saying, ‘Well, you really wanted a Snickers bar this morning, and then you ate three Snickers bars, and now how can you not want a Snickers bar? There's one right here.’ It's like, ‘Well, yeah, I really wanted one this morning, but I have three now, and it's more than enough.’ …
“I don't need to have another one of my own, because I understand that that baby is only a baby for a year, and they grow up and they still need things for 18 years, and I already have enough on my plate with the four that I have.”
Raphael Cohen-Almagor, of the University of Hull in the United Kingdom, is a world expert on euthanasia in the Netherlands and Belgium. He recently contributed an article to the JOurnal of Medical Ethics on one of the most worrying aspects of the euthanasia in Belgium—the deliberate shortening of lives of some patients without their explicit voluntary request. In this interview with BioEdge, he explains some of his concerns.
BioEdge: Are the figures of euthanasia cases rising?
Raphael Cohen-Almagor: Studies have shown a constant increase in registered euthanasia cases, predominantly in the Flemish (the Dutch-Flemish speaking part) of Belgium. Approximately one of seven terminally ill patients dying at home under the care of a general practitioner (GP) expresses a euthanasia request in the last phase of life. The annual figures are constantly rising: 235 in 2003; 495 in 2007; 704 in 2008, and 1,133 in 2011. In 2012, there were 1,432 cases and in 2013, 1,807 euthanasia cases were reported.
Are you sure about the statistics? The trends are confusing. You observe that in 2007 the use of life-ending drugs with the intention to shorten life and without explicit request occurred in 1.8% of deaths but in 2013 it was 1.7% of deaths. So contrary to what you have said, the situation seems to be improving, not getting worse, isn't it?
Research has shown that in 2007 the use of life-ending drugs with the intention to shorten life and without explicit request occurred in 1.8% of deaths and that in 2013 it was 1.7% of deaths. This is a slight improvement.
However, the overall situation is worrying. The enactment of the Euthanasia Act in 2002 was followed by an increase in almost all types of medical end-of-life practices: euthanasia, intensified alleviation of pain, withholding or withdrawing life-prolonging treatment, and continuous and deep sedation until death. The latter practice is especially worrying: In 2007, 14.5% of all deaths in Flanders were the result of continuous deep sedation until death. This is a significant increase compared to the number of cases, 8.2%, six years earlier.
When the Euthanasia Act was legislated, it was designated mainly for competent adults, capable and conscious at the time of their euthanasia request. Evidence has shown that now euthanasia has been stretched to incompetent patients, demented patients, psychiatric patients as well as to patients who are said to be “tired of life”.
Furthermore, in February 2014, the Belgian parliament voted to extend the euthanasia law to cover children under the age of 18. The law sanctions euthanasia for children with terminal or incurable conditions who are near death, suffering “constant and unbearable pain”, and whose parents and health professionals agree with the decision.
Thus the scope of end-of-life practices has been enlarged far beyond the good intentions of the legislature in 2002.
How do doctors justify involuntary euthanasia? On the basis of relieving suffering? Of saving money? Of sparing the feelings of relatives?
I have raised the question of economic considerations in the decision-making process time and again with Belgian experts. I was repeatedly told that saving money is never the issue. Research indicates that beneficence is often the guiding principle. Physicians wish to ease patients’ suffering and to ensure a relatively comfortable death.
Worryingly, sometimes they give priority to the best interests of the patient’s relatives over and above the patient’s best interest, wishing to alleviate the patient’s “burden” off the shoulders of the next of kin.
You say that “social and peer pressure makes it difficult for those who oppose euthanasia to uphold their position in the liberal culture that has been developing”. Does this mean that it is hard to work as a doctor or nurse in Belgium unless you support euthanasia?
In 2004 I published my book Euthanasia in the Netherlands: The Policy and Practice of Mercy Killing in which I asked Dutch scholars about “culture of death” in their country. My research in Belgium indicates some striking similarities.
As is the case in The Netherlands, the general atmosphere in Belgium is supportive of euthanasia. The Netherlands and Belgium are liberal societies, with strong emphasis on autonomy. The majority of people in both countries support the idea that patients should be able to decide the time of their death with the help and support of the medical profession.
Many people in many countries, myself included, support this idea. However, I do not think that the Dutch and Belgian public are fully aware of the whole picture in implementing the euthanasia policy, and of the many problematic aspects of the euthanasia practice in their respective countries.
In both countries, the establishment view is pro-euthanasia, and one might be harmed if one takes a contrary view. There is pressure on medical professionals to support euthanasia. In both countries, those who are opposed to euthanasia are tagged and dismissed as “religious fundamentalists” who fail to speak truth to reason.
Some Dutch and Belgian scholars and journalists struggle with my critique of the policy and practice of euthanasia as they cannot tag me as a “Catholic fundamentalist” and because I initially supported euthanasia on moral grounds and changed my mind on practical, policy grounds, restricting my plea to physician-assisted suicide. I changed my mind because of the abuse that is recorded in both countries. A fine line distinguishes between moral reasoning and policy making. I am unable to adhere to abstract moral reasoning while ignoring facts.
To illustrate the societal pressure on those who object to euthanasia let us consider the following example: Carol is an accomplished medical ethicist. She is opposed to euthanasia. In her university there is an opening for the chair in medical ethics. She submits an application. Her chances to be nominated are slim to none because thecChair serves as a consultant in euthanasia cases referred to her by hospitals affiliated with the respective university. If it is known that the professor objects to euthanasia, then there would be no point in consulting with her on this issue at a time when euthanasia does take place in hospitals.
Hence, it is necessary to fill important posts with like-minded people who will maintain the positive climate towards euthanasia. The only exceptions are Catholic universities.
Do Belgians realize that involuntary euthanasia is common in their country? How about the medical profession and the police?
Many Belgian and Dutch scholars and professionals who have reservations about the policy and practice of euthanasia voice their frustration in trying to raise questions, air doubts, and open debates about recorded problems.
The media on the whole are not interested. I recently granted a long interview to a Belgian daily newspaper and, as far as I know, not a word was published. The criticisms are voiced mainly outside Belgium and The Netherlands. These criticisms are dismissed by advocates of euthanasia because “foreigners do not understand us” and, anyway, “the situation is probably worse in other countries”. In Belgium and in The Netherlands, so the claim goes, “we are conducting our affairs in the open, in a candid and transparent way while no data is available for other countries”.
I have heard these arguments again and again. In fact, the Belgian, like the Dutch, actually do not welcome criticism and are quite conservative in their liberal attitude to euthanasia. Both countries are protective of their systems and believe that their euthanasia policy is correct and just.
Curiously, some of the leading Belgian scholars on euthanasia publish only the facts without any interpretation or reflection. I am yet to hear a convincing argument for this so-called “neutral” approach. I say so-called “neutral” because silence is also a stand.
Belgian (and also Dutch) people pride themselves on their openness, on their ability to discuss and debate life-and-death decisions openly. In this same spirit, they should openly debate the more intricate and problematic aspects of the euthanasia policy while having adequate knowledge about the various end-of-life practices.
The full picture of the data should be disclosed to the public. Transparency is indeed of vital importance in promoting and safeguarding patient’s autonomy at the end-of-life.
Does Belgium offer lessons for other countries which are considering euthanasia or assisted suicide?
There are many lessons to be learned from Belgium, both positive and negative. Let me mention only some of them, and I start of the positive:
The practice of medicine should be deontological rather than utilitarian. Patient’s autonomy and preferences should be respected as much as possible. The Belgian medical system on the whole manifests that.
Belgian palliative care has been developing and continues to develop. This is a great positive in the Belgian medical system. The World Health Organization (WHO) defines palliative care as the “active, total care of patients whose disease is not responsive to curative treatment,” maintaining that control of pain, of other symptoms, and of psychological, social, and spiritual problems, is paramount. The medical staff must examine whether it is possible to prevent or to ease the pain by means of medication and palliative care.
Belgian scholars continue to conduct surveys about the euthanasia practice and produce consecutive reports, also in English. This is certainly a good practice. Other countries should also strive to compile extensive reports of their own end-of-life practices.
The practice of a truly independent second opinion to verify the patient’s diagnosis and his/her voluntary wishes is a good example to follow. The Belgian themselves are still challenged to implement this practice in full for all patients but they are constantly trying to improve.
The insistence that the final act should performed by physicians is correct. The Belgian medical establishment is struggling with this directive as well; sometimes the practice is conducted by nurses, but professionals are aware of the problem and trying to remedy this.
Much of the euthanasia practice of ending life in Belgium and in The Netherlands is dependent on general practitioners. Physicians are increasingly aware of the very powerful role their recommendations can play in people's treatment choices, and of the undue ways their recommendations can influence patients. There is growing understanding of the importance of spending time with patients and having a candid conversation with them; getting patients to talk out loud about their values before making treatment recommendations. Quality care requires investing time and attention, opening and maintaining two-dual way physician-patient communication of listening and advising.
Physicians realise that often this type of conversation will make it easier for physicians to determine what recommendation is most appropriate for a patient and whether the patient is comfortable deciding what to do without receiving a recommendation.
The fact that physicians may not demand a special fee for the performance of euthanasia is appreciated.
Physicians should not be coerced into taking actions that conflict with their conscience. No coercion should be involved in the process. Conscientious objection should be respected.
On the negative side, the major lesson to learn from Belgium, and also The Netherlands, is not to legalize euthanasia. Despite the best intentions and the existing safeguards against abuse (which can be improved) both countries record too many instances of abuse.
The final act should be left in the hands of the patient, not in the hands of the physician. Unfortunately, some physicians are abusing the power given to them; they act paternalistically against the best interests of their patients.
About half of euthanasia cases are not reported. This lack of notification of euthanasia cases is worrying. Research reveals that physicians failed to notify the Federal Control and Evaluation Commission because they “had forgotten”; because they did not label cases that should be labelled euthanasia as such; because they found the procedural requirement of notification “burdensome and not useful”; because they felt euthanasia was a private matter, or because they failed to understand the legal requirements. More need to be done to study the differences between Flanders and Wallonia (Roman Catholic Walloon physicians find it more difficult than their Flemish colleagues to report euthanasia cases) and to clarify the logic of the Euthanasia Act to practitioners, explaining why the procedural requirements of the law are no less important than the substantive requirements.
Curiously, little is known about end-of-life practices in Wallonia. There is an urgent need to know how medical professionals in this region are conducting their affairs.
It is revealing that no physician has been charged for malpractice or abuse of power since the Euthanasia Act was introduced in 2002. The system is very protective of its physicians also when they act independently of the patient’s best interests.
Also worrying is the potential pressure on euthanized patients to donate their organs. The fact that euthanasia donors account for a very significant percentage of all lung donors should not go unnoticed.
Research has shown that there is a grey area in end-of-life care between treatments administered to relieve pain and suffering, and treatments aimed to shorten the life of the patient. Transparency and proper documentation are vital. They may serve as a safeguard against potential abuse. Records should be kept of the timing and doses of the drugs in use, and the physician’s intention at each step. Such documentation may reduce the use of inappropriate doses of medication given in the guise of relieving pain and suffering but actually intended to bring about the death of the patient. As a control mechanism, pharmacists should be required to file a report every time lethal medications are sold and records should be kept about their use.
Looking at the short history of the euthanasia laws, policy and practice, in Belgium and also in the Netherlands may lead us to think that there is something intoxicating about the practice that blinds the eyes of decision-makers, leading them to press forward further end-of-life practices without paying ample attention to caution.
In both countries, one cautionary barrier after the other are removed to allow greater scope for euthanasia. The logic of the 2002 Euthanasia Act that spoke of adults or emancipated minors was undermined in 2014 when the Belgians extended the law to all minors.
Although some patients are euthanized without explicit request (as mentioned, 1.7% of all deaths in 2013) the Belgians are not eager to push for more stringent control mechanisms. Quite the opposite: The scope of tolerance towards the practice of euthanasia is enlarged so that yesterday’s red light becomes obsolete today, and as this one is removed practitioners and law-makers are already debating a further step and other groups (patients who are “tired of life”, children, patients with dementia) to be included within the more liberal euthanasia policy.
This is quite astonishing as human lives are at stake. What is required is a careful study, accumulation of knowledge and data, addressing the above concerns, learning from mistakes and attempting to correct them before rushing like frenzy to introduce more liberal ways to euthanize patients. Haste makes waste.
Raphael Cohen-Almagor (DPhil., St. Catherine’s College, Oxford) is Professor and Chair in Politics at the University of Hull, UK. He was Assoc. Professor at the University of Haifa, Israel; Visiting Professor at UCLA and Johns Hopkins; Fellow, the Hastings Center and the Woodrow Wilson International Center for Scholars, USA; Visiting Scholar, Vrije Universiteit, The Netherlands. Raphael established the Medical Ethics Think-tank at the Van Leer Jerusalem Institute (1995-1998) and was among the drafters of Israel’s The Dying Patient Law (2005). Among his many books are The Right to Die with Dignity (2001), Euthanasia in the Netherlands (2004), Editor, Medical Ethics at the Dawn of the 21st Century (2000), Editor, Moral Dilemmas in Medicine (2002, Hebrew), and Confronting the Internet's Dark Side: Moral and Social Responsibility on the Free Highway (2015). Raphael is now writing a book about end-of-life practices in different countries. Twitter: @almagor35. Web: http://www.hull.ac.uk/rca. Blog: http://almagor.blogspot.com