VII. NORDIC COUNTRIES

This entry provides a brief overview of the modern development of medical ethics in the Nordic countries: Denmark, Finland, Iceland, Norway, and Sweden. The focus is primarily on the period after the beginning of the 1960s. The entry begins by giving an account of the establishment of ethics review committees and other medical ethics bodies and organizations. Then changes in the educational and research situation are described, along with the establishment of special institutions for medical ethics. Finally, attention is given to some essential features of the debate on a few principal issues.

Codes, Ethics Bodies, and Organizations

The attempt formally to regulate physicians' duties toward their patients and colleagues began early in the history of medicine. Ethics codes in the Nordic countries can be traced to the early practice of physicians taking an oath of office and allegiance. For example, in seventeenth-century Sweden, when physicians still received doctoral degrees abroad, usually in Holland, permission to practice medicine required the taking of an examination given by the Swedish association of physicians, the Collegium Medicorum, which was founded in 1663. When passing the examination the physician had to take a special oath. The taking of an oath was an obligatory part of the examination of physicians in Sweden until the late nineteenth century and still is required in Denmark, Finland, and Iceland.

It was only after World War II, however, that the making of ethics codes in the Nordic countries came to encompass areas outside clinical practice and to include professional categories other than physicians. The current ethical guidelines for physicians' clinical work were adopted in their original forms by the Danish Medical Association in 1976, by the Finnish in 1956, by the Icelandic in 1918, by the Norwegian in 1961, and by the Swedish in 1951. During the 1950s and 1960s other health professional groups, such as nurses and physical therapists, began to develop their current ethical codes. The 1964 adoption of the Helsinki Declaration by the World Medical Association extended the codification to the explicit inclusion of ethics in research. To facilitate its implementation the Nordic countries created a system of ethics review committees.

Those committees are organized somewhat differently in the different countries. Denmark and Norway have regional committees, whereas Finland and Iceland have local hospital committees and Sweden has both regional and local committees. The Danish system, which was established in 1978, consists of seven regional committees and a central scientific-ethical committee. The committees in Norway are organized in a similar way. In 1985 regional committees were set up in each of Norway's five national service regions. To establish a coordinating and advisory body for those regional committees, the Norwegian Medical Research Council's Committee for Medical Research Ethics, which was formed in 1978, became the National Committee for Medical Research Ethics in 1990. In Finland the first ethics committee was set up at Helsinki University in 1972; since 1977 all medical faculties have had ethics committees. In Iceland the two national university hospitals have had ethics committees since 1976. In Sweden an advisory council was formed at the Karolinska Hospital in Stockholm in 1965. That council was superseded the next year by the first medical-faculty ethics committee, which was established at the Karolinska Institute. By 1967 similar committees were in place at all medical faculties in that country.

Since those committees were established, the call for assessment of the ethical implications of new technologies and other advances in medicine has increased. To respond to growing pressures on political decision makers an additional type of national ethics body was created. Its principal task is twofold: to provide expert knowledge to the government, the parliament, and the health-service authorities and to contribute generally to a continuous exchange of information and opinions on medical ethics issues among researchers, politicians, and the public. To that end the Danish Council of Ethics was established by the parliament in 1987; the National Research Ethics Committee, by the Finnish Parliament in 1991; the National Biotechnology Advisory Board, by the Norwegian government in 1991; and the National Council of Medical Ethics, by the Swedish government in 1985. Iceland still lacks a national body of this kind. (For further information about the origin, composition, and activities of these national bodies and of the review committees see Council of Europe; Solbakk.) In 1988 the Nordic Committee for Ethics in Biotechnology was created by the Nordic Council of Ministers. Like some of the national bodies, this committee deals with bioethical issues in the broad sense of the term. Besides issues in medicine, the Nordic Committee addresses ethical questions in, for example, stockbreeding and agriculture.

Several other bodies and organizations play an important role in the analysis and debate of issues in medical ethics. For example, ethics committees were set up within the medical associations of Denmark (1969), Finland (1975), Norway (1962), and Sweden (1979), as well as within the National Finnish Board of Health (1988), the National Swedish Board of Health and Welfare (1984), and the Ministry of Health and Social Affairs in Norway (1988). In 1989 the Council of Ethics was established at the Office of the Director General of Health in Iceland. There are also a number of medical societies: the Delegation for Medical Ethics, established in 1969 within the Swedish Society of Medicine (earlier called the Swedish Society of Medical Sciences); the Society for Medical Law and Ethics, founded in Finland in 1980; the Danish Society for Medical Philosophy, Ethics, and Methodology, founded in 1988; and the Swedish Society for Medical Ethics, founded in 1989. In 1988 a section for medical ethics in the Nordic countries was established within the European Society for Philosophy of Medicine and Health Care.

Education and Research

Since the beginning of the 1970s medical ethics has been taught at medical faculties and nursing schools in all the Nordic countries. However, there are no uniform requirements regarding the scope and content of this teaching in any of the Nordic countries. At a meeting in Reykjavik, Iceland, in 1991, the medical associations of the Nordic countries agreed to work toward making medical ethics a compulsory subject at all medical faculties in those countries and creating teaching positions in the subject (Oldinger).

Textbooks have been written in most of the Nordic countries. For a long time Medicinsk etik (1971), a doctoral dissertation by Clarence Blomquist, a pioneer in Swedish medical ethics, was the only general introduction; it dealt with both metaethics and normative ethics and covered most of the principal issues in medical ethics at that time. Subsequently, a number of textbooks have appeared, including some broad general introductions (Fagerberg et al.; Andersen et al; Tranøy, 1991; Wretmark et al.), some more philosophically oriented works (Malmgren; Tännsjö, 1998), and some texts dealing not only with ethics but also with other philosophical issues in medicine (Bjarnason; Tranøy, 1978; Wulff et al).

The philosophical rather than the medical faculties have been responsible for most postgraduate education in medical ethics. Blomquist's Medicinsk etik, the first doctoral dissertation, was defended at the Department of Philosophy at Uppsala University in 1973. Since that time philosophy departments have produced dissertations on specific medical ethics issues such as suicide, paternalism, and abortion as well as on the nature and scope of philosophical medical ethics in general. Partly empirical doctoral dissertations that focus primarily on issues in medical ethics have been written within the fields of sociology, nursing research, and medicine.

The establishment of two special institutions for medical ethics, one in Norway and the other in Sweden, as well as the foundation of a unit for the philosophy of medicine in a broader sense in Denmark, has improved the opportunities at medical faculties for both graduate and postgraduate education in medical ethics. The Center for Medical Ethics at the University of Oslo was founded in 1989. A chair in medical ethics was created at the University of Oslo Medical Faculty in 1992. Lund University in Sweden established the Department of Medical Ethics in 1991. The department came into existence through the creation of a chair in medical ethics at the Swedish Medical Research Council in 1990. In 1988 the University of Copenhagen established the Unit of Medical Philosophy and Clinical Theory at the Panum Institute.

Those institutions have strengthened the position of medical ethics as an independent research field at medical faculties. Research in medical ethics otherwise is carried on normally only in the form of time-limited projects and mainly outside medical faculties in philosophy departments and departments of theology. Some institutions focus on medical ethics as a principal area of research. For example, the Department of Health and Society at Linköping University in Sweden has had a chair for the philosophy of medicine since 1987. Two institutes have been established: one in Iceland in 1989, the Ethics Institute at the University of Iceland, and the other in Sweden in 1988, the Ersta Institute for Health Care Ethics in Stockholm. In Finland the Center for Bioethics was founded in 1991 at the University of Turku.

Principal Issues

ARTIFICIAL INSEMINATION AND IN VITRO FERTILIZATION. Among the Nordic countries only Norway and Sweden have laws that specifically regulate the use of noncoital reproductive technologies to achieve pregnancy. The use of human sperm, ova, zygotes, and early embryonic forms (blastemas) for research purposes also is restricted in the Nordic countries.

The ethical and legal debate in the Nordic countries over the use of noncoital reproductive technologies has focused mainly on artificial insemination by donor semen (AID), in vitro fertilization (IVF), and ovum donation. The closely related issues of artificial insemination by the husband's semen (AIH) and gestational surrogacy (surrogate motherhood) have attracted less attention. Except among certain religious minorities the use of AIH has generally been accepted.

To a large extent the 1987 Norwegian legislation on artificial insemination and IVF corresponds to the 1985 Swedish legislation. One point on which the Norwegian and Swedish laws differ is of particular ethical interest: the issue of whether it should be possible for a child to obtain information about the identity of his or her natural father. Sweden legislated in favor of the child's right to this information, and Norway legislated against it.

According to the Swedish legislation, (1) only women married or cohabiting with a man in circumstances of marital character should be allowed to receive insemination treatment; (2) insemination requires written consent by the husband or cohabitant, who will by virtue of that act be regarded as the legal father of a child born as a result of the treatment; (3) AID should be undertaken only in general hospitals under the supervision of a physician who specializes in obstetrics and gynecology, and the sperm donor should be chosen by the physician; (4) information about the sperm donor should be kept in a special hospital record for at least seventy years; (5) when a child conceived by donor insemination is mature enough, he or she has a right to obtain information about the identity of the natural father; and (6) when requested, the public welfare committee is obligated to assist the child in retrieving that information. (For literature on the debate and official reports preceding this law see Lindahl, 1985, 1988; U.S. Congress.)

The most controversial issue has been the right to obtain information about a child's father. The main point of departure for the Swedish legislation was the needs and interests of the child. In this respect the legislators decided to follow the general direction of modern legislation toward a gradual strengthening of children's judicial standing and the movement in society toward greater openness in family relations rather than the traditional patient-oriented perspective of clinical medical ethics. These two contrasting perspectives have dominated much of the debate.

PRENATAL DIAGNOSTICS AND ABORTION. The laws on abortion vary among the Nordic countries. In Denmark women have a legal right to abortion regardless of the reason before the twelfth week (law of 1973, in force the same year); in Norway, until the end of the twelfth week (law of 1975, in force from 1979); and in Sweden, before the end of the twelfth week or, after special consultation with a social worker, up to the end of the eighteenth week (law of 1974, in force from 1975). In Finland (law of 1970, in force the same year) and Iceland (law of 1975, in force the same year) abortion is permissible before the twelfth week, but only on certain indications (see below).

The situation in Sweden illustrates the way in which the legal status of the fetus and the understanding of its relationship to the mother changed during the twentieth century. Until the abortion act of 1974 a fetus was viewed as a separate individual, even during the first three months, and thus was legally protected. According to the earliest legislation, in the eighteenth century, abortion carried a penalty of death because it was equated with infanticide. As late as the 1920s the penalty for abortion was one year's to six years' imprisonment at hard labor. However, exceptions were made if abortion was necessary to preserve the health or life of the woman. This practice was ratified by law in 1938. From 1939 abortion was permissible up to the end of the twentieth week on any of the following three indications: medical (i.e., when, because of disease, physical defect, or weakness, childbirth would cause serious danger to the life or health of the woman), humanitarian (e.g., pregnancy after rape or incest or in minors), and eugenic (when there was reason to believe that the expected child would inherit mental disease, mental deficiency, or serious physical disease). After the twentieth week abortion was permissible only on medical grounds. Two additional indications were introduced before the abortion act of 1974: in 1946, sociomedical (i.e., when, considering the living conditions and other circumstances, it might be assumed that childbirth or care of the child would reduce the woman's physical or emotional strength seriously) and in 1963 teratogenetic (i.e., when there was reason to believe that the expected child, as a result of injury during the fetal stage, would suffer from a serious disease or defect). All these indications, somewhat differently formulated, are still used in Finland and Iceland.

In the debate surrounding the 1974 law on abortion the fetus often was no longer viewed as a separate individual but as a part of the woman's body. Abortion therefore became, according to this view, not a matter of weighing the value of one individual's life against the value of another's but a question of a woman's right to make decisions about her own body. The only legal limit to that right is the point in time at which the fetus has become viable, that is, able to survive outside the uterus. In Sweden the operation still may be performed at that time, but only if the woman suffers from a disease or physical defect and continued pregnancy therefore constitutes a serious threat to her life or health. Unless the operation cannot be postponed without danger to the woman, permission from the National Board of Health and Welfare is always required after the eighteenth week of pregnancy.

That exception has been questioned in an official Swedish investigation of the abortion law (Justitiedepartementet, 1989). The investigation points out that because abortion, according to the common medical definition, amounts to the expulsion of a nonviable fetus, this exception must mean that the operation is performed in such a way that the fetus is dead at delivery. The investigation found that unacceptable and required that instead efforts be made to save the life of both the woman and the fetus at that stage of pregnancy.

The investigation calls attention to the reevaluation of the legal status of the fetus that was undertaken after the abortion law was instituted. During the 1980s recurrent demands were made that an unborn child be protected from the risk of injury resulting from the mother's abuse of alcohol or narcotics. That request led to the conclusion that the woman and the prospective child no longer can be viewed as a single individual.

EUTHANASIA AND THE CONCEPT OF DEATH. Until the 1990s the dominant view on euthanasia in the medical profession in the Nordic countries was virtually that expressed in the mid-1800s by the Finnish physician Immanuel Ilmoni in his book on medical ethics Om läkarens yrke och pligter (1847). Ilmoni called euthanasia one of the most important special disciplines of the art of medicine. At the same time he made it clear that a physician may not in any circumstances deliberately contribute to shortening the patient's life even in cases in which the patient is "incurably ill, tormented beyond description, [and] fervently desires and demands death" (pp. 45–46).

In the late 1960s and during the 1970s, when the debate on euthanasia was most intensive in the Nordic countries, it would have been hard to imagine the medical profession supporting legislation that allowed physicians to comply with a terminally ill patient's wish to die. Among the earliest and most thorough contributions to the debate was Clarence Blomquist's book on euthanasia, Livet, döden och läkaren (1964). In that book Blomquist discusses the five principal definitions of euthanasia that were used in the debate: (1) the original meaning: medical care in the terminal phase of life, for example, the mitigation or relief of pain and discomfort of the dying; (2) causing death as a predicted but not intended side effect of treatment; (3) the acceleration of death; (4) passive euthanasia: discontinuing treatment or refraining from initiating treatment; and (5) active euthanasia: intentional killing in accordance with the patient's explicit or implicit wish to die or irrespective of the patient's will. Obviously, these different forms of euthanasia may overlap.

A fundamental issue in the debate has been where to draw the line between life and death. Brain-related criteria of death were introduced by law in Finland in 1971, in Norway in 1977, in Sweden in 1988, in Denmark in 1990, and in Iceland in 1991. The introduction of those criteria eliminated a minor but important part of the problem.

Throughout the 1970s even euthanasia as part of medical care in the terminal phase of life was disputed. The administration of painkillers was restricted to prevent terminally ill patients from becoming addicted to those drugs. In Sweden, for example, that restriction was not lifted until 1979. There was also concern that a more liberal administration of painkillers and tranquilizers might shorten a patient's life. Blomquist was among those who found this unintentional form of euthanasia, as well as the passive form, morally justifiable but did not support active euthanasia. Others, such as the Swedish professor of practical philosophy Ingemar Hedenius, advocated active euthanasia.

In 1992 Denmark became the first Nordic country to break with the traditional legal view on medical care in the terminal phase of life, passing a law according to which, unless there is particularly good authority for acting differently, a physician may not initiate or continue life-sustaining treatment of a terminally ill patient against wishes expressed in the patient's "living will." The law further provides that in the absence of a living will the physician may discontinue or refrain from initiating treatment that may prolong the life of a terminally ill patient. The physician also may administer painkillers, tranquilizers, and similar substances necessary for easing a terminally ill patient's suffering even when that may shorten the patient's life.

Three organizations for terminal care have been formed: in Sweden in 1973, the national organization Right to Our Death; in Norway in 1977, the national association My Living Will—the Right to a Death in Dignity; and in Finland in 1993, EXITUS. In 1985 a special organization for active euthanasia, EXIT, was founded in Sweden.

Concluding Remarks

Among other areas that have attracted special attention in the Nordic countries are ethical problems in medical research, for example, questions of integrity and the difficulty of meeting the requirements of informed consent in epidemiological and healthcare research. The frequent use of personal numbers in computerized official registers provides unique potential opportunities for population studies. At the same time it creates special ethical problems (Hermerén). Another field of increasing importance is the ethical consequences of technological and scientific developments in human genetics (for an overview see Berg and Tranøy 1989; Bischofberger et al.; Therkelsen et al; Nordisk Ministerråd, 1992, 1994). Finally, the ethical questions of health economics and setting priorities in healthcare have been debated. In 1987 in Norway a government-appointed commission produced a report on guidelines for priorities in public healthcare (Sosialdepartementet).

From the early 1960s to the end of the 1990s medical ethics underwent a sweeping transformation in the Nordic countries. From being viewed primarily as a concern only between the patient and the physician and only between colleagues, medical ethics has evolved into a field of systematic studies and extensive interdisciplinary and public debate. The scope has broadened from discussions of normative ethical issues to include metaethical analyses of the norms, values, and basic concepts of medicine. General awareness of the conflicts of interest and the incompatibility of the goals inherent in medical decision making and research has increased considerably, a development that benefits both patients and medical professionals.

b. i. b. lindahl (1995)

revised by author

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