Content uploaded by Raphael Cohen-Almagor
Author content
All content in this area was uploaded by Raphael Cohen-Almagor on Jun 04, 2015
Content may be subject to copyright.
1
This article has been accepted for publication in Journal of Medical Ethics 2015 following
peer review. The definitive copyedited, typeset version will be available online at:
http://jme.bmj.com/
First Do No Harm: Intentionally Shortening Lives of Patients without Their
Explicit Request in Belgium
Raphael Cohen-Almagor
Abstract: The aim of this article is to provide a critical review of one of the most
worrying aspects of the euthanasia policy and practice in Belgium – the deliberate
shortening of lives of some patients without their explicit voluntary request. Some
suggestions designed to improve the situation and prevent abuse are offered.
Keywords: Belgium, end-of-life, euthanasia, abuse, competent patients, consent
Introduction
Since the enactment of the Belgian Euthanasia Act in 2002, biannual reports are
published by the Belgian Federal Control and Evaluation Commission, established
by the government in September 2002 and tasked to monitor the law’s application.
Euthanasia in Belgium is defined as the intentional termination of a patient’s life by a
physician at the patient’s request, thus only voluntary euthanasia is legally
sanctioned. Involuntary euthanasia which is the deliberate ending of life without the
patient’s explicit request is not legally permitted under the Belgian Euthanasia Act.
2
The aim of this paper is to raise concerns about the shortening of patients’
lives in Belgium without the patients’ explicit consent. First, background information
is provided. The paper surveys the published data and explains why this practice is
conducted in Belgium. It acknowledges a decrease of life-ending practices without
the patient’s explicit request and offers three possible explanations to this decrease.
The paper criticises explanations provided by some Belgian physicians for carrying
out this questionable practice. The paper also offers a critique of the Belgian Society
of Intensive Care Medicine Council statement paper on the administration of
sedative agents with the direct intention “of shortening the process of terminal
palliative care in patients with no prospect of a meaningful recovery”.
1
Finally, some
suggestions designed to improve the situation are offered. These proposals follow
conversations with Belgian medical ethicists and clinicians as to what might be an
acceptable practice at the present time, bearing in mind their own culture and
medical practices. The Belgian legislators and medical establishment are invited to
reflect and ponder so as to prevent potential abuse.
This paper is part of a research project on euthanasia in Belgium that
commenced in 2003.
2
Its methodology is based on critical review of the literature
supplemented by conversations, discussions and interviews that I have conducted in
Belgium with leading professionals (scholars and practitioners) during the past
eleven years (2003-2014). As I see little point in offering suggestions that would be
ignored by the Belgian medical profession, the extensive fieldwork in Belgium during
which I consulted relevant experts has both helped to formulate my claims and to
devise some constructive suggestions for improvement. The claims that I report from
my interviews have also been confirmed and verified by the existing literature
reported in this paper.
3
The Belgian Law and Beyond
On 20 January 2001, a commission of Belgium’s upper house voted in favour of
proposed euthanasia legislation, which would make euthanasia no longer punishable
by law, provided certain requirements were met.
3
On 25 October 2001, Belgium’s
Senate approved the law by 44 in favour, 23 against, 2 abstentions and 2 senators
who failed to register a vote. In Belgian society at large, an opinion survey showed
that three-quarters of those asked were broadly in favour of legalizing euthanasia.
4
On 16 May 2002, after only two days of heated debate, the Belgian lower house of
parliament approved the bill by 86 votes in favour, 51 against and with 10
abstentions.
5
The Socialist-Liberal-Green 'Purple coalition' overcame the objections
of the Christian Democrats. It is important to note that the euthanasia legalization
was finalized without the broad involvement of and consensus among the medical
professions.
6
While many physicians in Belgium wholeheartedly applauded the
Euthanasia Act, a considerable part of the medical profession remained silent and a
minority expressed reservations. In 2009, sixty-six percent of the sampled Belgian
physicians agreed that the euthanasia law contributes to the carefulness of
physicians' end-of-life behaviour; 10% thought that the law impedes the development
of palliative care.
7
The legislation lays out the terms for physicians to intentionally end the lives of
patients. At the heart of this legislation is the free will of the patient who asks for
euthanasia. The physician who performs euthanasia is not performing an unlawful
act if s/he has ascertained that the patient is an adult or an emancipated minor,
capable and conscious at the time of his/her request;
8
the request is voluntary, well-
thought-out and reiterated, and is not the result of outside pressure; the patient is in
4
a hopeless medical condition and complains of constant and unbearable physical or
mental pain which cannot be relieved and is the result of a serious and incurable
accidental or pathological condition, and s/he has complied with the conditions and
procedures prescribed by the present law.
9
The law sets certain conditions in order
to carry out euthanasia under terminal circumstances and defines extra conditions
for cases in which non-terminal patients request euthanasia. For the latter group of
patients (such as those who suffer from neurological conditions causing
quadriplegia) who request to die, at least one month must elapse between the
written request and the mercy killing, and the attending physician needs to consult a
psychiatrist or a specialist in the disorder in question.
10
The fourth report to the legislative chambers (2008‐2009), drawn up by the
Federal Commission for Control and Assessment of Euthanasia, showed that 92% of
the cases were concerned with lawful euthanasia practices with terminal patients
while 8% of the cases concerned non-terminal patients. The most often declared
illnesses mentioned to justify this latter type of request were primarily
neuropsychiatric diseases, followed by degenerative neuromuscular diseases and a
combination of non‐fatal “multiple pathologies”.
11
In recent years, however, the
practice of euthanasia has been extended to include people who were depressed,
and who were tired of and/or unhappy with their lives.
12
In early 2014, Belgium
became the first country to allow euthanasia for terminally ill children of any age.
Whether or not children have the experience and wisdom to make a sound choice
about such a grave decision is disputed.
13
Research also indicates some physicians'
confusion about and lack of understanding of the Euthanasia Act;
14
a problem of
inadequate consultation with an independent expert,
15
and a problem concerning
lack of notification of euthanasia cases.
16
Smets et al found that in Flanders, only
5
one of two euthanasia cases is reported to the Federal Control and Evaluation
Committee and that the unreported cases of euthanasia were generally dealt with
less carefully than the reported cases: a legally required written request was absent
in the majority of unreported cases; other physicians were consulted less in the
unreported cases than in the reported cases; the life-ending act was more often
performed with opioids, sedatives or both rather than with barbiturates and muscle
relaxants. Furthermore, in the unreported cases the lethal drugs were often
administered by a nurse alone, not by a physician.
17
Whether deliberately or not, the
physicians were disguising the end-of-life decision as a normal medical practice.
18
A constant increase in registered euthanasia cases has been observed,
predominantly in the Flemish (the Dutch-Flemish speaking part) of Belgium.
19
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.
20
A Flanders 2007 study (published in 2010) shows that euthanasia and physician-
assisted suicide occurred in 2% of all Flemish deaths.
21
This rate was higher than
that in 1998 (1.1%) and in 2001 (0.3%).
22
The annual figures are constantly rising at
a rapid pace: 235 in 2003; 495 in 2007; 704 in 2008, and 1,133 in 2011.
23
In 2012,
there were 1,432 cases and in 2013, 1,807 euthanasia cases were reported.
24
Shortening Lives of Patients without Their Explicit Request
In 2014, the Belgian Society of Intensive Care Medicine Council issued a statement
paper about the administration of sedative agents with the direct intention “of
shortening the process of terminal palliative care in patients with no prospect of a
meaningful recovery”.
25
The Statement holds that shortening the dying process by
administering sedatives “beyond what is needed for patient comfort can be not only
6
acceptable but in many cases desirable”,
26
that suffering should be avoided at all
times, and that avoiding futile treatment is not only acceptable but also necessary.
The Statement further stipulates that shortening the dying process with use of
medication may sometimes be appropriate, “even in the absence of discomfort”, and
can actually improve the quality of dying, that the final decision lies in the hands of
the medical care team, and that the document applies to children as well as to
adults.
27
This paternalistic attitude is not reserved only to intensive care physicians.
Studies conducted in Flanders, before the enactment of the 2002 euthanasia law,
showed that decisions to end life without patients’ consent were common among
general practitioners. A 1996 pilot study at the town of Hasselt in Flanders showed
that the administration of lethal drugs in order to shorten the patient’s life without the
patient’s request occurred in 3.3% of cases.
28
A 1998 study conducted in Flanders at
large, where 60% of the Belgian population resides, more than 5% of all deaths in
general practice resulted from the use of drugs with the explicit intention of
shortening the patient’s life.
29
Bilsen et al wrote that during the studied period of time
“an estimated 1,200 ELDs (medical end-of-life decisions) in general practice were
made illegally”.
30
The administration of lethal drugs in order to shorten patients’ lives
without their explicit request occurred in 1,796 cases (3.2 percent).
31
Deliens et al
noted that in Flanders the rate of administration of lethal drugs to patients with the
explicit intention of shortening the patient's life without their explicit request was
similar to Australia, and significantly higher than that in the Netherlands.
32
In 2007, the use of life-ending drugs with the intention to shorten life and
without explicit request occurred in 1.8% of deaths
33
and in 2013 it was 1.7% of
deaths.
34
Three possible explanations to this decrease from 3.2% in 1998 to 1.7% in
7
2013 are (1) physicians have gained experience and confidence in the practice of
euthanasia and involve the patients in the decision-making process; (2) physicians
resort to practices such as terminal sedation which is different than euthanasia;
35
(3)
physicians may not always be well acquainted with the labelling of all the medical
practices at the end of life.
36
The ambiguity creates confusion and affect research
results.
Use of life-ending drugs without explicit request involved patients who were
80-year-old or older (52.7%), those with disease other than cancer (67.5%), and
those in hospital (67.1%). The decision was not discussed with the patient in 77.9%
of cases. Physicians explained that the decision was not discussed because the
patient was comatose (70.1%), had dementia (21.1%) or because discussion would
have been harmful to the patient’s best interest (8.2%).
37
Similar reasoning was
given in the Hasselt study two decades earlier: “because this was clearly the best for
the patient” (28.2%); because of “diminished consciousness” (26.5%); because “the
patient was unconscious” (18.5%), and due to dementia (13.6%).
38
However, the
patient’s best interest argument was far less significant in 2007 (8.2%) than it was in
1996 (28.2%). In contrast, the dementia argument was much more prevalent in 2007
(21.1%) than it was in 1996 (13.6%). It should also be reminded that the law
specifically stipulates that “the patient is an adult or an emancipated minor, capable
and conscious at the time of his/her request,”
39
thus lives of incompetent comatose
and demented patients should not be shortened under the Euthanasia Act.
40
The Act
does not apply to non-competent patients and it does not allow deliberate shortening
of their lives. It should also be noted that deliberate ending the lives of patients
without their request is taking place in Belgium more than in all other countries that
document such practices, including the Netherlands (0.4% in 2005).
41
It is worrying
8
that some physicians take upon themselves the responsibility to deliberately shorten
patients’ lives without a clear indication from the patients that this is what they would
want.
Physicians were asked in what circumstances they ended the lives of patients
without explicit request and described two types of situation: Shortening the length of
the patient’s final phase of agony during the last phase of the dying process, and
facilitating the death of the “terminally ill, demented and inhumanly deteriorated
patient”.
42
Their aims were to shorten the length of misery considered to be futile, to
ensure a relatively comfortable death and, most worryingly, to alleviate the burden of
the next of kin.
43
Thus defenders of the euthanasia policy in Belgium argued that life-
ending acts without explicit patient’s request should be seen as “compassionate
intended abbreviation of terminal agony”.
44
Another study by Meeussen, Van den Block, Bossuyt et al found that the
practice of explicitly and intentionally shortening lives of patients without explicit
request to die involved some patients who suffered from incurable lingering
diseases, and whose quality of life was perceived to be poor by the medical teams.
The patients were all bedridden and incapable of self-care in what was estimated as
the last phase of their lives. Their medical situation was mainly characterized as
“unbearable” and involving “persistent suffering.”
45
Most of the patients were
“unconscious or in a coma.”
46
All but one patient had lost the capacity to assess their
situation and to make an informed decision about it. One patient was considered
competent but was unable to express himself well.
47
Critique and Suggestions for Improvement
9
The practice of deliberately shortening patients’ lives without explicit request and
consent is ethically problematic and also illegal in most countries including Belgium.
From physicians’ testimonies, it appears that they acted out of compassion and
chose what they believed to be the least bad option in futile medical situations. Yet
the wishes of the patients were unknown to the physicians. Several questions are
provoked by the forgoing account: Should physicians deliberately end the lives of
patients who might still wish to continue living, despite all the odds? Should this
issue be left to the discretion of physicians? Can physicians reliably estimate the
length of time that patients have left to live? Belgian physicians who were involved in
this problematic practice estimated life-shortening effect by one week or more for
6.4% of cases.
48
How precise is this estimation?
49
Furthermore, at what stage does
treatment cease to be meaningful and become futile?
Reading the Belgian Society of Intensive Care Medicine Council Statement
evokes nagging concerns. The word “consent” is not mentioned. The Statement
asserts that a “consensus should be obtained for every end-of-life decision,”
50
that
the decisions remain “the responsibility of the ICU physician”,
51
that once this
consensus decision is made, “all members of the team must apply the plan that has
been decided on,”
52
and that while the plans for end-of-life care should be discussed
with and understood by the patient’s relatives or surrogate, this rather laconic
statement emphasises again that “the final decision is made by the care team and
not by the relatives”.
53
The tone of the Statement is paternalistic, manifesting a belief that the
intensive care physicians are capable to discern when patients have no prospect of a
“meaningful recovery” (the term “meaningful” is not explained), when treatment
becomes “futile” (the assumption is that we all agree what “futile” means), and when
10
patients “are arriving, irreversibly, at the end of their life”
54
(no indication is given of
how this potentially self-fulfilling diagnosis is to be reliably made). Furthermore,
relatives should be informed of prognosis and plans for end-of-life care but it is
emphasised yet again, that it “must be made clear that the final decision is made by
the care team”.
55
The Statement is said to uphold the principles of beneficence and
nonmaleficence. Respecting a patient’s autonomy and her wishes are not
mentioned. The decision as to which life is no longer “worth living” is not in the hands
of the patient but in the hands of the doctor.
Jean-Louis Vincent, a former president of the Society, explained in a
newspaper op-ed that because at intensive care units death usually follows after a
decision is made to stop treatment, and because this decision is often accompanied
by an increase of tranquillizers, “euthanasie non demandée” (“euthanasia not asked
for”) exceeds considerably the few thousand cases of “euthanasie demandée”
(“euthanasia asked for”) that are registered in Belgium annually.
56
Vincent explicated
that increasing drugs to relieve all pain or providing tranquillizers to prevent agitation
or anxiety were not at issue; rather his focus was on hastening death when the
patient’s quality of life has become insufficient. Vincent maintained that patients in
such a condition are not conscious enough to express an explicit demand, and that
these active interventions to shorten life are not reported to the Federal Control and
Evaluation Commission. Vincent maintained that Belgium needs a law that clearly
condemns “therapeutic stubbornness” and he invited an open and collegial
discussion about the possibility of offering drugs that shorten life of too mediocre
quality. This is even when the patient did not sign a consent paper. Vincent
concluded by saying that the first goal of medicine is to restore or maintain health,
11
that is to say restore or maintain the well-being of the individual. The first goal of
medicine is not to maintain life at all costs.
57
In 2008, I asked Vincent whether he was in favour of the law. Vincent’s answer
was: “The law may serve some who deal with slowly progressing diseases, but is
more deleterious than helpful in the majority of cases, i.e. in patients who are not
fully conscious towards the end of their life. In the ICU we often increase the doses
of sedative agents at the end of life, but the person has not signed any document, so
that this may become unlawful.”
58
At the very least it seems that these concerns should be opened for a public
debate. As Chambaere et al rightly note, the use of life-ending drugs without explicit
request of the patients occurred predominantly among groups of vulnerable patients:
80 year-old patients or older who were mostly in coma or suffered from dementia.
59
The Belgian population should be aware of the present situation and know that if
their lives may come to the point where physicians think they are not worth living, in
the absence of specific living wills advising physicians what to do then, they might be
put to death.
To clearly mark the difference between treatments administered to relieve pain
and suffering, and treatments aimed to shorten the patient’s life, transparency and
proper documentation are vital. 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.
60
12
The medical staff should be made aware of the differences between voluntary
and involuntary euthanasia, relating to patient’s consent and autonomy, the
performance of the two practices, and the explicit legal directives for euthanasia.
Ethical education in medical schools and in hospital rounds should include
discussions about the requirements of the Euthanasia Act, and about the medical
requirements of due care. Open discussions are recommended relating to the
decision-making process and who should be involved in it: physicians, the patient
and all the people around the patient’s bed: her loved ones and friends, nurses,
palliative care professionals, social workers, psychologists and others. Physicians
may also benefit from discussion on decision-making processes and the appropriate
use of opioids and other medications that might shorten life.
Guidelines and adequate control mechanisms are necessary to prevent abuse
of power and to facilitate trust conferred on physicians to heal, support and provide
care for people when they are most needy and helpless.
61
Medical records should
include documentation relating to the medical condition, patients’ expressed wishes,
the decision-making process, discussions with the patient and/or her loved ones, the
palliation medication that was administered, the use or lack of use of artificial
hydration and nutrition, and the effects of the intervention.
Conclusions
Although the legalization of euthanasia was finalized without the broad involvement
and consensus among the medical profession, the acceptance of euthanasia among
Belgian medical professionals has increased from 78% in 2002 to more than 90% in
2009.
62
Social and peer pressure makes it difficult for those who oppose euthanasia
13
to uphold their position in the liberal culture that has been developing. Similar
difficulties have been recorded in the Netherlands following the legislation of the
Dutch euthanasia law.
63
Johan Bilsen and colleagues found that the enactment of
the Euthanasia Act was followed by an increase in 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) with the
exception of the use of life-ending drugs without explicit request.
64
The use of drugs with the explicit intention to shorten life and without the
patient’s volition still continues to linger on and should be addressed adequately. The
liberal state has an obligation to protect the vulnerable. Given that ending patients’
lives without request is more common than euthanasia,
65
it is suggested to urge the
Belgian medical profession to put this issue high on its agenda. The lives of many
patients are still shortened involuntarily. Even Chambaere et al who are not critical of
life-ending acts without the patient’s explicit request implicitly acknowledge that in
31.9% of the cases they studied the practice was problematic.
66
The Belgians are
researching the way their dying patients are being handled in a medical context.
Their culture of self-searching is certainly necessary. The Belgians should ensure
that their policy is not abused.
In his critique of this paper, Dan Callahan asks the following: If Belgium has
been unable to control abuse -- and does not seem to have tried very hard -- what
reason is there to believe it will be controlled in the future? Indeed, the situation in
Belgium presents a true challenge. It is not easy to control abuse. At the same time,
opinion polls indicate that the majority of the Belgian public, 85% to 93% of them,
support euthanasia
67
and it would be coercive to deny them what they perceive as a
fundamental right. The good news is that the history of the euthanasia in Belgium is
14
young. The Euthanasia Act was passed only in 2002, and the country is still in the
early learning stages. We can hope that the Belgians learn from their experience and
will devise ways to address the concerns.
Acknowledgements
I am most grateful to J. Berre, Bert Broeckaert, Luc Deliens, Jan De Volder, Chris
Gastmans, Pierre-François Laterre, Wim Lemmens, Freddy Mortier, Guido Van
Steendam and Jean-Louis Vincent for their kind assistance. I also thank Dan
Callahan, Raanan Gillon, as well as the editor and referees of JME for their
constructive comments. All websites were accessed on 2 April 2015.
1
Vincent J-L., “Piece” (sic) of mind: End of life in the intensive care unit Statement of the Belgian
Society of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174-175.
2
Other research products include: Belgian Euthanasia Law: A Critical Analysis, JME 2009; 35(7):
436–39; Euthanasia Policy and Practice in Belgium: Critical Observations and Suggestions for
Improvement, Issues in Law & Medicine 2009; 24(3): 187-218; First Do No Harm: Pressing Concerns
Regarding Euthanasia in Belgium, Int. J. of Law & Psychiatry 2013; 36: 515-21; First Do No Harm:
Euthanasia of Patients with Dementia in Belgium, J. of Medicine & Philosophy (2015, forthcoming).
3
Weber W., Belgian Euthanasia Bill gains momentum, Lancet 2001; 357: 370.
4
Deliens L., van der Wal G. The Euthanasia Law in Belgium and the Netherlands, Lancet 2003; 362,
Issue 9391: 1239-40; Osborn A., Belgians follow Dutch by legalising euthanasia, The Guardian
26
October 2001.
5
Griffiths J., Weyers H., and Adams M., Euthanasia and law in Europe. Oxford: Hart, 2008: 304-329;
Vermeersch E., The Belgian Law on euthanasia - The historical and ethical background, Acta chir
belg 2002; 102: 394-7.
15
6
Smets T., Cohen J., Bilsen J. et al., Attitudes and experiences of Belgian physicians regarding
euthanasia practice and the Euthanasia Law, Journal of Pain & Symptom Management 2011; 41(3):
581.
7
Smets T., Cohen J., Bilsen J. et al., Attitudes and experiences of Belgian physicians regarding
euthanasia practice and the Euthanasia Law, Journal of Pain & Symptom Management 2011; 41(3):
581.
8
Freddy Mortier, professor of ethics at Ghent University, explained that emancipated minors relate to
”boundary cases of 16-17 year old patients.” Mortier argued that there were very few cases of
emancipated minors who received help to die by doctors. Interviews with F. Mortier, Ghent (6
February 2003 and 14 February 2005). See Cohen-Almagor R., Belgian Euthanasia Law: A Critical
Analysis, JME 2009; 35(7): 436–39.
9
Belgian Act on Euthanasia, Chapter II, Section 3, no. 1, http://www.ethical-
perspectives.be/viewpic.php?LAN=E&TABLE=EP&ID=59. One referee commented that the line
between lawful euthanasia and other end-of-life practices is blurred and creates confusion.
10
Belgian Act on Euthanasia, Chapter II, Section 3, no. 3(2).
http://www.ethical-perspectives.be/viewpic.php?LAN=E&TABLE=EP&ID=59
11
Euthanasia in Belgium: 10 years on, Dossier of the European Institute of Bioethics,
http://www.livinganddyingwell.org.uk/sites/default/files/LDW%20-%20Research%20-
%20Belgium%20-%2010-Year%20Review_0.pdf
12
Cohen-Almagor R, First Do No Harm: Euthanizing People Who Are “Tired of Life” in Belgium,
paper presented in Euthanasia and Assisted Dying: Lessons from Belgium, The Anscombe Bioethics
Centre, Oxford and St Mary’s University, Twickenham (1 November 2014).
13
Siegel AM, Sisti DA, Caplan AL, Euthanasia for minors in Belgium, JAMA 2014; 312(12): 1259;
Kelly D, Euthanasia for children and young people?, International J. of Palliative nursing 2014; 20(5):
211.
14
Smets T, Bilsen J, Cohen J et al., The labelling and reporting of euthanasia by Belgian physicians:
A study of hypothetical cases, European Journal of Public Health 2012; 22(1): 19-26.
15
Van Wesemael Y, Cohen J, Bilsen J et al. Process and outcomes of euthanasia requests under the
Belgian act on euthanasia: A nationwide survey, Journal of Pain and Symptom Management 2011;
16
42: 721–733; Smets T, Bilsen J, Van den Block L et al., Euthanasia in patients dying at home in
Belgium: Interview study on adherence to legal safeguards, British J. of General Practice 2010; 60
(573): e163–e170.
16
Smets T, Bilsen J, Van den Block L et al., Euthanasia in patients dying at home in Belgium:
Interview study on adherence to legal safeguards, British J. of General Practice 2010; 60 (573):
e163–e170; Smets T, Bilsen J, Cohen J et al., The labelling and reporting of euthanasia by Belgian
physicians: A study of hypothetical cases, European J. of Public Health 2012; 22 (1): 19-26,
http://eurpub.oxfordjournals.org/content/early/2010/12/03/eurpub.ckq180.full
17
Smets T, Bilsen J, Cohen J et al., Reporting of euthanasia in medical practice in Flanders, Belgium:
cross sectional analysis of reported and unreported cases, BMJ 2010; 341, c5174.
18
Smets T, Bilsen J, Cohen J et al., Reporting of euthanasia in medical practice in Flanders, Belgium:
cross sectional analysis of reported and unreported cases, BMJ 2010; 341, c5174.
19
Smets T., Bilsen J., Cohen J. et al., Legal euthanasia in Belgium: characteristics of all reported
euthanasia cases, Medical Care 2010; 48: (2): 187-92; Bilsen J., Cohen J., Chambaere K. et al.,
Medical end-of-life practices under the Euthanasia Law in Belgium, NEJM 2009; 361: 1119-21; Rise
in assisted deaths 23 August 2011, Presseurop, http://www.presseurop.eu/en/content/news-brief-
cover/878961-rise-assisted-deaths
20
Meeussen K., Van den Block L., Bossuyt N. et al., Dealing with requests for euthanasia: interview
study among General Practitioners in Belgium, Journal of Pain & Symptom Management 2011; 41(6),
p. 1068.
21
Chambaere K., Bilsen J., Cohen J. et al., Physician-assisted deaths under the Euthanasia Law in
Belgium: a population-based survey, Canadian Medical Association Journal 2010; 182(9): 896.
22
Bilsen J., Cohen J., Chambaere K. et al., Medical end-of-life practices under the Euthanasia Law in
Belgium, p. 1119.
23
de Diesbach E., de Loze M., Brochier C., and Montero E., Euthanasia in Belgium: 10 years on
(Brussels: European Institute of Bioethics, 2012): 3.
24
Commission Fédérale de Contrôle et d’Évaluation de l’Euthanasie. 2014 Report. Service
Public Federal (SPF) Sante publique, Securite de la Chaine alimentaire et Environnement (Brussels:
17
Secrétariat de la Commission),
http://www.health.belgium.be/filestore/19097638/Rapport_Euthanasie12-13_FR.pdf . See also
Caldwell Simon, “Five people killed EVERY DAY by assisted suicide in Belgium as euthanasia cases
soar by 25 per cent in last year alone”, The Daily Mail (28 May 2014).
25
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174-175.
26
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174-175, at 174.
27
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174.
28
Mortier F., Deliens L., Bilsen J., et al., End-of-life decisions of physicians in the city of Hasselt
(Flanders, Belgium), Bioethics 2000; 14(3): 254-267, at 257, 259.
29
Bilsen J., Vander Stichele R., Mortier F. et al., The incidence and characteristics of end-of-life
decisions by GPs in Belgium, Family Practice 2004; 21(3): 283.
30
Bilsen J., Vander Stichele R., Mortier F. et al., The incidence and characteristics of end-of-life
decisions by GPs in Belgium, Family Practice 2004; 21(3): 286.
31
Deliens L., Mortier F., Bilsen J. et al., End-of-life decisions in medical practice in Flanders, Belgium:
A nationwide survey, Lancet 2000; 356: 1806.
32
Deliens L., Mortier F., Bilsen J. et al., End-of-life decisions in medical practice in Flanders, Belgium:
A nationwide survey, Lancet 2000; 356: 1806.
33
Chambaere K., Bilsen J., Cohen J. et al., Physician-assisted deaths under the Euthanasia Law in
Belgium: A population-based survey, p. 896.
34
Chambaere K., Vander Stichele R., Mortier F. et al., Recent trends in euthanasia and other end-of-
life practices in Belgium, N Eng J Med 2015; 372;12 (19 March),p. 1179.
35
Broeckaert B., Mullie A., Gielen J., et al., Palliatieve Sedatie, Richtlijn, Versie: 2.0 2012,
http://www.pallialine.be/accounts/129/docs/richtlijn_palliatieve_sedatie.pdf; Broeckaert B., Mullie A.,
Gielen J., et al., Palliative sedation Directive, Version: 2.0 (30 June 2012, in English).
36
Deyaert J., Cohen J., Chambaere K. et al. Labelling of end-of-life decisions by physicians, JME
2014; 40: 505-507.
18
37
Chambaere K., Bilsen J., Cohen J. et al., Physician-assisted deaths under the Euthanasia Law in
Belgium: A population-based survey, pp. 895-8.
38
Mortier F., Deliens L., Bilsen J., et al., End-of-life decisions of physicians in the city of Hasselt
(Flanders, Belgium), Bioethics 2000; 14(3): 254-267, at 261. There is no information about the
remaining cases.
39
Belgian Act on Euthanasia, Chapter II, Section 3, no. 1,
http://www.ethical-perspectives.be/viewpic.php?LAN=E&TABLE=EP&ID=59
40
Cohen-Almagor R., First Do No Harm: Euthanasia of Patients with Dementia in Belgium, J. of
Medicine & Philosophy (forthcoming).
41
Van der Heide A., Onwuteaka-Philipsen B., Rurup MI., et al., End-of-life practices in the
Netherlands under the Euthanasia Act, N. Engl. J. Med. 2007; 356: 1957-65.
42
Sercu M., Pype P., Christiaens T., et al, Are general practitioners prepared to end life on request in
a country where euthanasia is legalised?, J Med Ethics 2012; 38: 277.
43
Sercu M., Pype P., Christiaens T., et al, Are general practitioners prepared to end life on request in
a country where euthanasia is legalised?, J Med Ethics 2012; 38: 277. For further discussion, see
Pivodic L., Van den Block L., Pardon K. et al., Burden of family carers and care-related financial
strain at the end of life: a cross-national population-based study, European J. of Public Health (17
March 2014).
44
Bernheim JL., Wim Distelmans W., Mullie A., Questions and Answers on the Belgian Model of
Integral End-of-Life Care: Experiment? Prototype? Bioethical Inquiry 2014; 11:507–529; Chambaere
K., Bilsen J., Cohen J. et al., Physician-assisted deaths under the Euthanasia Law in Belgium: a
population-based survey, Canadian Medical Association Journal 2010; 182(9): 895-901.
45
Meeussen K., Van den Block L., Bossuyt N. et al., Physician reports of medication use with explicit
intention of hastening the end of life in the absence of explicit patient request in general practice in
Belgium, BMC Public Health 2010; 10: 186.
46
Meeussen K., Van den Block L., Bossuyt N. et al., Physician reports of medication use with explicit
intention of hastening the end of life in the absence of explicit patient request in general practice in
Belgium, BMC Public Health 2010; 10: 186.
47
Meeussen K., Van den Block L., Bossuyt N. et al., Physician reports of medication use with explicit
intention of hastening the end of life in the absence of explicit patient request in general practice in
19
Belgium, BMC Public Health 2010; 10: 186.
48
Deyaert J., Chambaere K, Cohen J. et al., Labelling of end-of-life decisions by physicians, J Med
Ethics 2014; 40: 506.
49
Poses RM
,
Bekes C, Copare FJ, Scott WE, The answer to "What are my chances, doctor?"
depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients, Crit
Care Med. 1989; 17(8):827-33.
50
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174.
51
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174.
52
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174.
53
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174-175.
54
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 174.
55
Vincent J-L., “Piece” of mind: End of life in the intensive care unit Statement of the Belgian Society
of Intensive Care Medicine, J of Critical Care 2014; 29(1): 175.
56
Vincent J-L, Carte blanche: “Maintenons la santé, mais pas la vie à tout prix”, Le Soir (25 February
2014), http://www.lesoir.be/478262/article/maintenant-sur-lesoirbe/2014-02-25/carte-blanche-
maintenons-sante-mais-pas-vie-tout-prix .
57
Vincent J-L, Carte blanche: “Maintenons la santé, mais pas la vie à tout prix”, Le Soir (25 February
2014), http://www.lesoir.be/478262/article/maintenant-sur-lesoirbe/2014-02-25/carte-blanche-
maintenons-sante-mais-pas-vie-tout-prix . See also Cook M., Belgian intensive care doctors back
involuntary euthanasia, BioEdge (11 April 2014).
58
Personal communication of Professor Jean-Louis Vincent (10 December 2008).
59
Chambaere K., Bilsen J., Cohen J. et al., Physician-assisted deaths under the Euthanasia Law in
Belgium: a population-based survey, Canadian Medical Association Journal 2010; 182(9): 899.
20
60
Sprung CL., Ledoux D., Bulow, HH., et al., Relieving suffering or intentionally hastening death:
where do you draw the line?, Crit. Care Med. 2008; 36(1): 8-13.
61
UNESCO Universal Declaration on Bioethics and Human Rights (2005).
62
Smets T., Cohen J., Bilsen J., et al., Attitudes and experiences of Belgian physicians regarding
euthanasia practice and the Euthanasia Law, p. 590; Miccinesi G., Fischer S., Paci E., et al.,
Physicians’ attitudes towards end-of-life decisions: a comparison between seven countries, Social
Science and Medicine 2005; 60(9): 1961-1974; Van Wesemael Y., Cohen J., Bilsen J., et al.,
Implementation of a service for physicians’ consultation and information in euthanasia requests in
Belgium, Health Policy (online 5 January 2012).
63
Cohen-Almagor R, Euthanasia in the Netherlands (Dordrecht: Springer-Kluwer, 2004).
64
Bilsen J., Cohen J., Chambaere K. et al., Medical end-of-life practices under the Euthanasia Law in
Belgium, p. 1120.
65
van der Heide A., Deliens L., Faisst K. et al. End-of-life decision-making in six European countries:
Descriptive study, Lancet 2003; 362: 345-50.
66
Chambaere K., Bernheim JL., Downar J., et al., Characteristics of Belgian ‘life-ending acts without
explicit patient request’: a large-scale death certificate survey revisited, CMAJ Open 2014; 2(4): E262-
E267.
67
Cohen-Almagor R., Belgian Euthanasia Law: a critical analysis, J Med Ethics 2009; 35(7): 436–9.